NORTH COUNTRY CHILDREN’S CLINIC INTERIM HISTORY 6-21 YRS.

NAME:__________________________________________DOB:_____________DATE:___________

For children under 12, the parent or guardian is asked to please help the child fill this out.

Since your last physical, check those areas where you have had problems:

Allergies: drug, food or environmental	Coughs or wheezes	Nurses Notes
Your eyes	Feeling short of breath
Glasses/contacts	Heart Problems
Your ears – infections or hearing problems	Stomach problems – pain, nausea, vomiting
Your nose – stuffiness, nose bleeds, sinus infections	Diarrhea/constipation/soiling
Your teeth – cavities, dental work, bleeding gums	Bladder or kidney problems, bedwetting
Sore throat/hoarseness	Hernia
Neck lumps/swollen glands	Testicle problems
Breast lumps	Vaginal or penile sores or discharges/HIV, STD’s
Chest pain	Headaches
High blood pressure	Faintness/dizziness
Joint/muscle pain or swelling	Fatigue/weakness
Broken bones	Seizures
Scoliosis/back pain	Anxiety
Anemia/low iron	Attention Deficit Disorder
Easy bruising	Injuries
Rashes or acne	Hospitalizations/surgery
Hives	Other problems

Do you wear glasses or contacts?_________________ When was your last eye exam?______________

When was your last dental exam?_________________

Reviewed by___________________ Form# PC129

NAME:_________________________________________DOB:____________DATE:____________

1. Who usually cooks for you?_________________________________________________________

2. What is your favorite supper?________________________________________________________

3. What is your favorite snack?________________________________________________________

4. What is your favorite drink?_________________________________________________________

5. Do you eat breakfast? Yes No at home?_______________ or at school?______________

6. Do you get a school lunch or do you bring your lunch?___________________________________

7. What do you have for a snack when you get home from school?____________________________

8. Do you drink milk and eat cheese and yogurt?__________________________________________

9. How many glasses of milk do you drink each day?_______________________________________

10. What are your favorite fruits?_______________________________________________________

11. How many fruits do you eat each day?________________________________________________

12. What are your favorite vegetables?___________________________________________________

13. How may vegetables do you eat each day?_____________________________________________

14. Do you like meat? Yes No If no, why?___________________________________________

If yes, what kind?______________________________________

15. Do you eat spaghetti? Yes No

bread? Yes No

rice? Yes No

cereal? Yes No

16. Do you go to McDonald’s or Burger King? Yes No Other__________________________

17. How often do you drink a glass of water?______________________________________________

18. How often do you drink soda or kool-aid?_____________________________________________

19. Do you have enough food at your house? Yes No

20. Do you ever feel hungry when you go to bed at night? Yes No

If yes, why?_____________________________________________________________

Reviewed by:______________________________________________

NUTRITION SCREENING

NAME:____________________________________DOB:_______________DATE:______________

ADOLESCENT’S ONLY (Ages 11-21 yrs.)

21. How do you feel about the way you look?_____________________________________________

22. How do you feel about your weight?_________________________________________________

23. What would you like to weigh?______________________________________________________

24. Have you lost or gained weight in the last 3 months?_____________________________________

How?_____________________________________________________________________

Why?_____________________________________________________________________

How much?________________________________________________________________

25. Do you ever skip meals purposely? Yes No

26. Do you binge? Yes No

NOTES

Reviewed by______________________________

NCCC: 11/01, 11/03

Form#: PC135