Unexplained weight gain or loss?
Recent fever (above 100)
Eczema, itching, rashes, or large birth marks?
Eye surgery, glasses, or contact lens?
Recurrent infection, congestion, or discharge in or from the ears/nose/throat/mouth?
Heart murmurs, shortness of breath, high blood pressure?
Asthma, chest pain, recurrent cough?
Feeding problems, diarrhea, constipation, vomiting?
Kidney or bladder infection, pain with urination, inability to control urine?
Other joint pains, fractures?
Seizures, head trauma, delayed age for walking or talking, attention deficit disorders, learning issues at school?
Depression, behavioral problems, addiction?
Any known problems with thyroid, growth hormone, diabetes?
Bleeding problems, easy bruising, frequent nose bleeds, low blood count, sickle cell disease?
Recurrent unexplained arm or leg swelling, bumps or knots under the arm or in the groin
Environmental allergies, food allergies, sensitivity to costume jewelry or balloons?
If over Age 14 Menstrual History
Do you drink alcohol? Yes No (Females over age 10)
Do you use tobacco? Yes No Have you started your periods? Yes No
(smoking or chewing) If yes, how long ago?
When was you last period?