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    Children Name :  
  Children Birthday :
  Gender : Male   Female
  Phone No. :
  Reservation :
  Mother E-Mail Address :
  Children weight :
  Children height :
  Chief Complain:
  Medical History:
  Family History:
   
    1.Usually does not eat food well.
  2.Amount of food intake is small.
  3.Has unbalanced diet; child only eats what he/she likes
  4. Has frequent stomach ache.
  5. Throws up often.
  6. Has bad breath.
  7. Gets car sick.(nauseated).
  8. Sensitive to smell .
  9. Tongue is discolored.
  10.Child has bowl movement times every day(s).
  11. Child's excreted feces are firm.
  12. Feces are flaccid.
  13. Had constipation problems in the past.
  14. Suffered from diarrhea and enteritis.(inflammation of the small intestine.)
  15. Often catches cold.
  16. Cold lasts more than 7 days.
  17. Neck swells often.
  18. Has swollen tonsils; big tonsils.(existence of adenoids)
  19. Has lot of heat overall in the body.
  20. Does not like being hot.
  21. Drinks lot of liquid.
  22. Sweats a lot.
  23. Sweats a lot even 2hours after falling asleep.
  24. Hands and feet are always cold.
  25. Has rough and dry sken.
  26. Easily tired agter playing or going outside.
  27. Has weak legs and trips over things often.
  28. Wakes up easily from sleep even from small noises.
  29. Sleeps very late.
  30. Often wakes up during sleep and cries.
  31. Sleeps with mouth open.
  32. Child is overly acute, sensitive.
  33. Easily scared.
  34. Has a tantrum; easily irritated and/or has quick temper.
  35. Child is an active type and bustles around busily.