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Amman / Jordan & Abu Dhabi / UAE Tel 00-962-6-569-1960-Amman Tel 00-971-50-818-1553- Abu Dhabi

New Patient Consult form for Appointment with Total Wellness Clinic

Patient's Name (first, middle, last): Preferred Name:

Today's Date:

Email Address:

Patient's Date of Birth:

Street Address:





Mother's First/Last Name and Age:

Mother's Occupation:

Father's First/Last Name and Age:

Father's Occupation:

Mobile Number:

Phone Number:

Who lives in the house?

Pregnancy Information: (Describe anything out of the ordinary)


Induced: .YES. .....

....NO. Forceps: .YES. .....


C-section: .YES. ..


Breast feeding: (Describe the length and character of feeding effort)

Colic or milk intolerance? (yes/no) Describe symptoms:

Formula: (Brand name or type)

When was food introduced?

Date or age you suspected delayed development:

Does your child speak? YES.. ........NO..

If not, does your child make sounds? Describe:

Did your child lose spoken words? If so, describe speech regression:

Frequency and age of first ear infection(s):

Did your child lose social and/or motor skills? (yes/no) Describe:

Did you associate a decline in your child's functions after a vaccine? (MMR, DPT, Polio, etc.)

Does your child have asthma/allergies? Describe:

Major food cravings:

List all foods commonly consumed:

Toilet trained? YES.. ........NO.. Describe bowel movements:

What age?

Does your child have violent or defensive behavior? ........YES.. What type of touch bothers your child? Describe:


Describe the activities of daily living you must help your child with (dressing, feeding, bathing, etc.):

What aspects are most troubling to you?

Describe your child's sleep pattern from birth to now in simple terms:

List all therapies your child has received:

List all current therapies:

School programs and grade level:

List all medications currently used: (Any medication allergies?)

List any medications that have failed to help and those that reacted badly with your child:

List all current nutritional supplements:

List any nutritional supplements that you think have helped your child:

What has benefited your child the most?

Is your child Right or Left Handed?

List any accidents or trauma:



Toys in mouth?



Surgery (list all procedures and dates)

Other medical problems: (check yes next to the appropriate box) .Heart......... .Chest....... .Sinuses........ .Skin........ Vision.... .Abdomen/Digestion .Walking/Running........

.Bones/Joints ......... .Genetic Others:


List all diagnostic tests performed on your Child: (Chromosomes, MRI, EEG, etc.)

What are your goals for your child's medical care? (in order of importance)

Is your child Hyperactive with short attention span?

Any thing else you want us to know about your child behavior?


Maternal Hx thyroid/auto immunity?

Any Family illnesses in mother or father side?

What else you would like us to know about your child?

Thank you. Please fill this form and bring it with you or E mail it to us at: Abu Dhabi / UAE and Gulf area: [email protected] Amman /JORDAN area: [email protected]


Microsoft Word - New_Patient_Consult_form.doc

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