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Please enable JavaScript in your browser to complete this form. Patient Demographic Information Child Name * First Last Child Date of Birth * Sex *MaleFemaleTransgender MaleTransgender FemaleUnspecified Email * Zip Code Phone Number * Weight/ Height Weight(kg/lb) * Height(cm/ft) * Father's height(cm/ft) Mother's height(cm/ft) Other Information What was your child's body shape when he/she was 3-4 years old? Tall and overweight Short and overweight Skinny and tall Skinny and short Average height and weight He/she feels cold all the time. Yes No He/she sweats a lot while sleeping. Yes No He/she is a picky eater. Yes No He/she does not eat much. Yes No He/she has no appetite. Yes No He/she often complains of a stomachache. Yes No He/she gets a cold more than 3 times a year. Yes No Cold lasts long. Yes No Coughing is a common symptom of his/her cold. Yes No He/she is very active. Yes No He/she is introverted and sensitive. Yes No He/she has trouble falling asleep. Yes No He/she has a lot of anxiety and keeps waking up in the middle of the night. Yes No He/she often complains of pain in the leg. Yes No Do you have any specific question or concern? Submit