| Name | Label | Folder | |
|---|---|---|---|
|
med1a1
Ever had acute life threatening episode (ALTE)?
|
Ever had acute life threatening episode (ALTE)? | Medical History | |
|
med1a2
Diagnosed or treated by a physician for acute life threatening episode (ALTE)?
|
Diagnosed or treated by a physician for acute life threatening episode (ALTE)? | Medical History | |
|
med1a3
Acute life threatening episode (ALTE) still present?
|
Acute life threatening episode (ALTE) still present? | Medical History | |
|
med1a4
Currently taking medication for the acute life threatening episode (ALTE)?
|
Currently taking medication for the acute life threatening episode (ALTE)? | Medical History | |
|
med1b1
Ever had an anxiety disorder?
|
Ever had an anxiety disorder? | Medical History | |
|
med1b2
Diagnosed or treated by a physician for an anxiety disorder?
|
Diagnosed or treated by a physician for an anxiety disorder? | Medical History | |
|
med1b3
Anxiety disorder still present?
|
Anxiety disorder still present? | Medical History | |
|
med1b4
Currently taking medication your anxiety disorder?
|
Currently taking medication your anxiety disorder? | Medical History | |
|
med1c1
Ever had asthma?
|
Ever had asthma? | Medical History | |
|
med1c2
Diagnosed or treated by a physician for asthma?
|
Diagnosed or treated by a physician for asthma? | Medical History | |
|
med1c3
Asthma still present?
|
Asthma still present? | Medical History | |
|
med1c4
Currently taking medication for asthma?
|
Currently taking medication for asthma? | Medical History | |
|
med1d1
Ever had Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder(ADHD)?
|
Ever had Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder(ADHD)?
Also known as Attention Deficit Hyperactivity Disorder (ADHD) |
Medical History | |
|
med1d2
Diagnosed or treated by a physician for Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder(ADHD)?
|
Diagnosed or treated by a physician for Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder(ADHD)?
Also known as Attention Deficit Hyperactivity Disorder (ADHD) |
Medical History | |
|
med1d3
Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder(ADHD) still present?
|
Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder(ADHD) still present?
Also known as Attention Deficit Hyperactivity Disorder (ADHD) |
Medical History | |
|
med1d4
Currently taking medication for Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder(ADHD)?
|
Currently taking medication for Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder(ADHD)?
Also known as Attention Deficit Hyperactivity Disorder (ADHD) |
Medical History | |
|
med1e1
Ever had cancer?
|
Ever had cancer? | Medical History | |
|
med1e2
Diagnosed or treated by a physician for cancer?
|
Diagnosed or treated by a physician for cancer? | Medical History | |
|
med1e3
Cancer still present?
|
Cancer still present? | Medical History | |
|
med1e4
Currently taking medication for cancer?
|
Currently taking medication for cancer? | Medical History | |
|
med1f1
Ever had cerebral palsy?
|
Ever had cerebral palsy? | Medical History | |
|
med1f2
Diagnosed or treated by a physician for cerebral palsy?
|
Diagnosed or treated by a physician for cerebral palsy? | Medical History | |
|
med1f3
Cerebral palsy still present?
|
Cerebral palsy still present? | Medical History | |
|
med1f4
Currently taking medication for cerebral palsy?
|
Currently taking medication for cerebral palsy? | Medical History | |
|
med1g1
Ever had heartburn or acid reflux?
|
Ever had heartburn or acid reflux? | Medical History | |
|
med1g2
Diagnosed or treated by a physician for heartburn or acid reflux?
|
Diagnosed or treated by a physician for heartburn or acid reflux? | Medical History | |
|
med1g3
Heartburn or acid reflux still present?
|
Heartburn or acid reflux still present? | Medical History | |
|
med1g4
Currently taking medication for heartburn or acid reflux?
|
Currently taking medication for heartburn or acid reflux? | Medical History | |
|
med1h1
Ever had depression?
|
Ever had depression? | Medical History | |
|
med1h2
Diagnosed or treated by a physician for depression?
|
Diagnosed or treated by a physician for depression? | Medical History | |
|
med1h3
Depression still present?
|
Depression still present? | Medical History | |
|
med1h4
Currently taking medication for depression?
|
Currently taking medication for depression? | Medical History | |
|
med1i1
Ever had diabetes?
|
Ever had diabetes? | Medical History | |
|
med1i2
Diagnosed or treated by a physician for diabetes?
|
Diagnosed or treated by a physician for diabetes? | Medical History | |
|
med1i3
Diabetes still present?
|
Diabetes still present? | Medical History | |
|
med1i4
Currently taking medication for diabetes?
|
Currently taking medication for diabetes? | Medical History | |
|
med1j1
Ever had an eating disorder?
|
Ever had an eating disorder?
This includes anorexia and bulimia |
Medical History | |
|
med1j2
Diagnosed or treated by a physician for an eating disorder?
|
Diagnosed or treated by a physician for an eating disorder?
This includes anorexia and bulimia |
Medical History | |
|
med1j3
Eating Disorder still present?
|
Eating Disorder still present?
This includes anorexia and bulimia |
Medical History | |
|
med1j4
Currently taking medication for an eating disorder?
|
Currently taking medication for an eating disorder?
This includes anorexia and bulimia |
Medical History | |
|
med1k1
Ever had eczema?
|
Ever had eczema?
Also known as atopic dermatitis |
Medical History | |
|
med1k2
Diagnosed or treated by a physician for eczema?
|
Diagnosed or treated by a physician for eczema?
Also known as atopic dermatitis |
Medical History | |
|
med1k3
Eczema still present?
|
Eczema still present?
Also known as atopic dermatitis |
Medical History | |
|
med1k4
Currently taking medication for eczema?
|
Currently taking medication for eczema?
Also known as atopic dermatitis |
Medical History | |
|
med1l1
Ever had hay fever?
|
Ever had hay fever?
This includes nasal allergies |
Medical History | |
|
med1l2
Diagnosed or treated by a physician for hay fever?
|
Diagnosed or treated by a physician for hay fever?
This includes nasal allergies |
Medical History | |
|
med1l3
Hay fever still present?
|
Hay fever still present?
This includes nasal allergies |
Medical History | |
|
med1l4
Currently taking medication for hay fever?
|
Currently taking medication for hay fever?
This includes nasal allergies |
Medical History | |
|
med1m1
Ever had hypertension (HTN)?
|
Ever had hypertension (HTN)?
Also known as high blood pressure |
Medical History | |
|
med1m2
Diagnosed or treated by a physician for hypertension?
|
Diagnosed or treated by a physician for hypertension?
Also known as high blood pressure |
Medical History | |
|
med1m3
Hypertension still present?
|
Hypertension still present?
Also known as high blood pressure |
Medical History | |
|
med1m4
Currently taking medication for hypertension?
|
Currently taking medication for hypertension?
Also known as high blood pressure |
Medical History | |
|
med1n1
Ever had high cholesterol?
|
Ever had high cholesterol? | Medical History | |
|
med1n2
Diagnosed or treated by a physician for high cholesterol?
|
Diagnosed or treated by a physician for high cholesterol? | Medical History | |
|
med1n3
High cholesterol still present?
|
High cholesterol still present? | Medical History | |
|
med1n4
Currently taking medication for high cholesterol?
|
Currently taking medication for high cholesterol? | Medical History | |
|
med1p1
Ever had headaches?
|
Ever had headaches?
Such as migraines or chronic severe headaches |
Medical History | |
|
med1p2
Diagnosed or treated by a physician for headaches?
|
Diagnosed or treated by a physician for headaches?
Such as migraines or chronic severe headaches |
Medical History | |
|
med1p3
Headaches still present?
|
Headaches still present?
Such as migraines or chronic severe headaches |
Medical History | |
|
med1p4
Currently taking medication for headaches?
|
Currently taking medication for headaches?
Such as migraines or chronic severe headaches |
Medical History | |
|
med1q2
Diagnosed or treated by a physician for autism?
|
Diagnosed or treated by a physician for autism? | Medical History | |
|
med1q3
Autism still present?
|
Autism still present? | Medical History | |
|
med1q4
Currently taking medication for autism?
|
Currently taking medication for autism? | Medical History | |
|
med1r1
Ever had asperger's syndrome?
|
Ever had asperger's syndrome? | Medical History | |
|
med1r2
Diagnosed or treated by a physician for asperger's syndrome?
|
Diagnosed or treated by a physician for asperger's syndrome? | Medical History | |
|
med1r3
Asperger's syndrome still present?
|
Asperger's syndrome still present? | Medical History | |
|
med1r4
Currently taking medication for asperger's syndrome?
|
Currently taking medication for asperger's syndrome? | Medical History | |
|
med1s1
Ever had other significant medical conditions?
|
Ever had other significant medical conditions? | Medical History | |
|
med1s2
Diagnosed or treated by a physician for other significant medical conditions?
|
Diagnosed or treated by a physician for other significant medical conditions? | Medical History | |
|
med1s3
Other significant medical conditions still present?
|
Other significant medical conditions still present? | Medical History | |
|
med1s4
Currently taking medication for other significant medical conditions?
|
Currently taking medication for other significant medical conditions? | Medical History | |
|
med2
Does your child have allergies?
|
Does your child have allergies? | Medical History | |
|
med2a
If Yes, has your child ever been tested (skin or blood) for allergies?
|
If Yes, has your child ever been tested (skin or blood) for allergies? | Medical History | |
|
med2b1
Child has mold allergy
|
Child has mold allergy | Medical History | |
|
med2b2
Child has tree allergy
|
Child has tree allergy | Medical History | |
|
med2b3
Child has cat allergy
|
Child has cat allergy | Medical History | |
|
med2b4
Child has insect allergy
|
Child has insect allergy | Medical History | |
|
med2b5
Child has dust allergy
|
Child has dust allergy | Medical History | |
|
med2b6
Child has grass or pollen allergy
|
Child has grass or pollen allergy | Medical History | |
|
med2b7
Child has dog allergy
|
Child has dog allergy | Medical History | |
|
med2b8
Child has food or drink allergy
|
Child has food or drink allergy | Medical History | |
|
med2b9
Child has latex allergy
|
Child has latex allergy | Medical History | |
|
med2b98
Child has other allergy
|
Child has other allergy | Medical History | |
|
med2b_other
Other allergies, specify
|
Other allergies, specify | Medical History | |
|
med2b_other_rc
Other allergies, specify (reclassed)
|
Other allergies, specify (reclassed) | Medical History | |
|
med3
Has your child ever had surgery requiring an over night stay?
|
Has your child ever had surgery requiring an over night stay? | Medical History | |
|
med3a2
Surgery Date performed
|
Surgery Date performed | Medical History | |
|
med3b2
Surgery Date performed
|
Surgery Date performed | Medical History | |
|
med4a
Referred to Cardiologist (Heart Doctor)
|
Referred to Cardiologist (Heart Doctor) | Medical History | |
|
med4b
Referred to Gastroenterologist (Stomach Doctor)
|
Referred to Gastroenterologist (Stomach Doctor) | Medical History | |
|
med4c
Referred to Pulmonologist (Lung Doctor)
|
Referred to Pulmonologist (Lung Doctor) | Medical History | |
|
med4d
Referred to Neurologist
|
Referred to Neurologist | Medical History | |
|
med4e
Referred to Otolarynologist (Ear, Nose, & Throat Doctor)
|
Referred to Otolarynologist (Ear, Nose, & Throat Doctor) | Medical History | |
|
med4f
Referred to Psychiatrist / Psychologist
|
Referred to Psychiatrist / Psychologist | Medical History | |
|
med4g
Referred to Sleep Specialist
|
Referred to Sleep Specialist | Medical History | |
|
med5
Child's weight at birth?
|
Child's weight at birth? | Medical History | |
|
med5_chk
What was your child's weight at birth
|
What was your child's weight at birth
Not sure |
Medical History | |
|
med5_tot_oz
Childs birth weight total ounces
|
Childs birth weight total ounces | Medical History | |
|
med6
Was your child born early (prematurely, or 4 or more weeks early)?
|
Was your child born early (prematurely, or 4 or more weeks early)? | Medical History | |
|
med7
Did your child need oxygen for more than one day after birth?
|
Did your child need oxygen for more than one day after birth? | Medical History |