InitialHQ

Initial Health History Questionnaire
Please fill in this form before your initial appointment.
- age 0 - 2
- age 3 - 12
- Adult

Initial Health History Questionnaire (age 0-2)

* 必須項目

Name *

名

姓

Preferred time and date *

Email address *

Reason for this appointment for your baby. *

When did you notice it? *

How did it start? *

Has your child been seen by Dr. with this condition? *

About General Health of your child

How many hours does you child sleep at night? *

How many hours does your child take a nap? *

Does your child have a preferred sleeping postion *

Does you child go to sleep easily? *

Does you child have a preferred sleeping position? *

Does your child have any feeding difficulties? *

Dose your child have any skin rashes? *

Had your child had any falls or trauma? *

If yes, please describe the trauma and date it occurred? *

Has your child ever had a broken bone? *

Has your child ever had ear infections? *

Has your child ever had colic? *

Has your child had asthma? *

Is your child allergic to anything? *

Is your child currently receiving any medications? *

Has your child ever been to an emergency room? *

If yes, when and why? *

Any additional comments or concerns? *

Thank you for completing this questionnaire!
Please press the send button.

Send

Initial Health History Questionnaire (age 3- 12)

* 必須項目

Name *

名

姓

Preferred time and date *

Email address *

Please describe your child problem or concern *

When did it start? *

How did it start? *

When does your child complain the problem *

Since it began, is your child's problem *

Has your child had similar condition in the past? *

Has your child been seen by Dr. with this condition? *

About General Health of your child

How many hours does you child sleep at night? *

Does your child have a preferred sleeping postion *

Does you child go to sleep easily? *

Does you child have a preferred sleeping position? *

Does your child have any feeding difficulties? *

Had your child had any falls or trauma? *

If yes, please describe the trauma and date it occurred? *

Has your child ever had a broken bone? *

Has your child ever had ear infections? *

Has your child had asthma? *

Any additional comments or concerns? *

Thank you for completing this questionnaire!
Please press the send button.

Send

Initial Health History Questionnaire (age 0-2)

About General Health of your child

Initial Health History Questionnaire (age 3- 12)

About General Health of your child

Initial Health Questionnaire (Adult)

Thank you for completing this questionnaire!
Please press the send button.

☎　080-3979-1518

Hiromi's カイロ

Initial Health History Questionnaire (age 0-2)

About General Health of your child

Initial Health History Questionnaire (age 3- 12)

About General Health of your child

Initial Health Questionnaire (Adult)

Thank you for completing this questionnaire!Please press the send button.

☎ 080-3979-1518

Hiromi's カイロ

Thank you for completing this questionnaire!
Please press the send button.

☎　080-3979-1518