PEDIATRIC HOLISTIC HEALTH CENTERS OF AMERICA
Eric N. Rydland, M.D.
1921 Commonwealth Dr. Charlottesville, VA 22901-2382
434-984 KIDS, Fax: 434-984-5439
DrRydland@kidswellness.com
www.kidswellness.com

PATIENT INFORMATION FORM Please take a few minutes to complete the following information so that we may better provide for your family’s medical needs. Please complete all pages and answer all questions as much as possible. Due to the nature of our work we do not bill insurance. You will be supplied with the necessary paperwork to process your own insurance claim upon payment.

Please indicate by whom you were referred:

DATE:

PATIENT’S NAME:

DATE OF BIRTH:
SEX:
PERMANENT ADDRESS:



LOCAL ADDDRESS (if different):

TELEPHONE NUMBERS:

EMAIL(S):

FATHER’S NAME/AGE:
EMPLOYER NAME:

ADDRESS:

WORK TELEPHONE:

TYPE OF WORK:

MOTHER’S NAME/AGE:
EMPLOYER NAME:

ADDRESS:


WORK TELEPHONE: 

TYPE OF WORK:

CHILD LIVES WITH:

NAME AND TELEPHONE OF EMERGENCY CONTACT:


MEDICAL INFORMATION
Allergies:

FAMILY MEDICAL HISTORY
NAMES AND AGES OF ALL SIBLINGS:

Please list all family members who have any chronic or serious illness or conditions related to that of the patient. In addition, if there are any known inherited conditions that have occurs in any family member, however related, please list. Include relation to patient, condition or disease, current age and age condition began  
1.
2.
3.
4.
5.
6.
7.

PRENATAL AND BIRTH HISTORY
1. Is the patient adopted?
2. How many weeks was the birth mother pregnant (40 weeks is the due date)? 
3. What type of delivery (e.g. vaginal, cesarean, vacuum, etc.)
4. If other than vaginal, why? 
5. What anesthesia or pain medicines used during labor or delivery?
6. Were treatments used to start (induce) or strengthen contractions?
7. Were any antibiotics given during labor, delivery, or after delivery (include details)?
8. Place of birth:
9. How long was the baby in the hospital, if applicable?
10. Weight and length at birth:
11. During the first month of life did the baby have any illnesses or problems, take medicines or have any tests other than routine tests (include details)? 

12. During the pregnancy were there any illnesses or treatments (include details)?

13. Has the birth mother ever during her life had any vaginal infections (include details)? 
14. What vitamins and/or other nutritional supplements were taken during the pregnancy?

DIETARY HISTORY
1. How long did the patient breast feed?
2. During breastfeeding did the mother experience any breast related problems,
including sore nipples, plugged ducts, breast itching/pain or mastitis (include details)?
3. What formulas did the patient take and at what ages? 

4. When did he/she begin solid foods?
5. What vitamins or nutritional supplements is the patient taking?

6. Please describe the current diet:



7. How much water does he/she drink daily? 
8. List foods he/she craves:
9. How often does he/she have a bowel movement?
10. What are the bowel movements like?
11. Describe any symptoms related to any particular foods:

MEDICAL HISTORY
1. List and describe any hospitalizations:

2. Describe any accidents, falls or other injuries:

3. Surgeries:
4. Childhood illness and year(s) (e.g. chicken pox, measles, mumps, rubella):
5. How many ear infections? 
6. How many throat infections treated with antibiotics? 
7. Pneumonia or bronchitis (details):
8. Has he/she ever been treated for thrush or other fungal infections internal or skin?
9. Are there any other illnesses that are a concern to you (include details)?

10. Are his/her vaccines/immunizations current?
11. Has he/she or any family member had reactions to any vaccines?
12. Please list all medications he/she is taking:

13. Does anyone smoke anywhere around the patient?
14. Have there been any concerns related to either growth or development (speech, motor, etc., detail on the back of this page)

Dr. Rydland strives to provide you with complete medical evaluations and appropriate treatment options for all of your children’s medical conditions. We want to do all we can to restore vibrant health and not just focus on eliminating disease. To do so we need to have regularly updated information about your child’s change(s) in condition and recommendations of other treating practitioners. Please have any specialists or other practitioners forward information regarding their evaluations and proposed treatments or send us this information yourself. Dr. Rydland is available for telephone calls after regular office hours, but will either need to see your child or do a telephone consultation regarding some more involved conditions. There is a charge for some telephone consultations and an additional charge for office visits performed outside of our normal business hours. Not all medical services are covered by medical insurance. Although we recommend you contact your insurance company prior to any medical treatments or tests, it is important to understand that they may later deny coverage for any of these. We do our best to supply you with the necessary information to bill your insurance, but cannot be held responsible for the errors of the insurance companies.

I agree to the above (sign here):
Printed name:
Date: