You can pre-evaluate the child’s health by answering the questions in this questionnaire.
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1. Mark if any of your family members (including relatives of the mother and father of the child) have or had congenital heart defects |
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2. Mark if there have been sudden deaths in your family under the age of 50 |
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3. Mark the box if any of your family members have had cases of sudden paroxysmal increase in heart rate (heart rate from 160 to 250 beats / min) |
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4. Mark the box if any memebers your family has had a myocardial infarction or stroke before the age of 50 |
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5. Mark the box if the mother of the child had swelling, changes in the urine, high blood pressure during pregnancy |
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6. Mark the box if the pregnancy was premature |
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7. Mark the box if the child had a desire to eat chalk, earth, smell varnishes, paints, gasoline |
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8. Mark the box if your child often had (or is ill) with colds |
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9. Mark the box if the mother or father of the child was diagnosed with duodenal ulcer |
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10. Mark the box if your child has had or has foci of infection in the nasopharynx (chronic runny nose, inflammation of the tonsils, middle ear, sinuses, adenoids) |
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11. Mark the box if your child has had or has a neurosis |
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12. Mark the box if your child has had or has giardiasis |
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13. Mark the box if your child has had earlier or has ascariasis |
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14. Mark the box if you often use (or used) antibiotics in treating a child |
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15. Mark the box if the child had C-hepatitis disease |
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16. Mark the box if your child has allergies |
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17. Mark the box if the child has had head injuries |
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