About Pregnancy Pediatrics Conditions New Patients Blog Supplements Contact Schedule your appointment Perfect Storm QuestionnaireChild's AgeWhat are your child's primary challenges? Did you have fertility challenges? Yes No Was there any extra stress or challenges with your pregnancy? Yes No If yes, please provide a short description (i.e. high risk, etc.) Was intervention needed during the birth process for your child? (most common examples include: induction, epidural, vacuum, forceps, c-section) Yes No If yes, please list: As an infant did your child have any breast feeding difficulties, colic, reflux, constipation, etc.? Yes No Has your child frequently been sick with ear infections and other respiratory challenges (exp. RSV, croup, etc.)? Yes No Has your child been on antibiotics before? Yes No If yes, about how many rounds approximately? Does your child suffer from autoimmune challenges like asthma and allergies? Yes No If yes, please list: Have you tried medications for your child’s current challenges? Yes No If yes, which ones: How did you hear about the Perfect Storm Workshop? At HFW Another Professional/Provider Facebook A friend or family member Other Δ Home About New Patients Blog Contact 8128 W 143rd. St. Orland Park, IL | (708)-349-0040
