New patient forms (child)

PEDIATRIC INTAKE FORM

PATIENT’S NAME _______________________________

DATE OF BIRTH ________________________________

ADDRESS__________________________________________

HOME PHONE # ________________________________

CELL #_________________________
EMAIL ADDRESS ___________________________________

PARENT’S/GUARDIAN’S NAMES ________________________

PARENT’S OCCUPATION______________________________

PEDIATRICIAN’S NAME AND # __________________________

WHOM MAY WE THANK FOR YOUR REFERRAL TO THIS CLINIC?

REASON FOR REFERRAL

CHIEF CONCERNS	HOW LONG HAS IT BEEN GOING ON?	HOW HAS IT BEEN TREATED SO FAR?	HAS THE TREATMENT BEEN SUCCESSFUL?
1.
2.
3.

PRENATAL HISTORY

Mom's Health at conception: Excellent Good Fair Poor

Age at Conception: _____

How would you describe your diet during the pregnancy? ___________________________
_____________________________________________________________________

Did you recieve any vaccines during your pregnancy? Yes No

If yes, which ones? _______________________________________________

Were you exposed to any toxic chemicals during your pregnany? (paint off-gasing,

home renos, pesticide sprays, photography chemicals, hair treatments, etc)

______________________________________________________________

Please fill out the following chart and circle those conditions/interventions that

you experienced during your pregnancy:

BIRTH HISTORY

PREGNANCY LENGTH (WEEKS) _________________

Circle that which applies:

HOME BIRTH
HOSPITAL BIRTH
MIDWIFE
G.P.
O.B.
VAGINAL BIRTH
C-SECTION
PAIN MEDS? (WHICH) ___________________________________________

ANY COMPLICATIONS WITH THE LABOR OR THE BIRTH? _______________________

_____________________________________________________________________

HEALTH HISTORY

PLEASE CIRCLE ANY OF THE FOLLOWING YOUR CHILD HAS EXPERIENCED:

MEASLES	BLEEDING GUMS	RUBELLA	TONSILITIS	WORMS
HEPATITIS	VOMITING	POLIO	ECZEMA	CHRONIC RASHES
COLDS/FLU	NIGHTMARES	HIVES	NIGHT SWEATS	DIARRHEA
SORE THROATS	MUMPS	HEADACHES	ODORS	ASTHMA
HEART MURMURS	CHICKEN POX	SLEEP APNEA	DEPRESSION	CONSTIPATION
FOOD ALLERGIES	MENINGITIS	THRUSH	CRADLE CAP	HYPERACTIVITY
STOMACH ACHES	CANKER SORES	HEARING LOSS	BURNING ON URINAITON	BLOODY URINE
EXCESSIVE FATIGUE	WHEEZING	ACNE	ENVIRONMENTAL ALLERGIES	ANEMIA
NOSE BLEEDS	MOTION SICKNESS	GAS/COLIC	JOINT PAINS	BLOODY STOOL
IRRITABLILITY	SLEEP PROBLEMS	EYE INFECTIONS	LOSS OF APPETITE	HAIR LOSS
HEPATITIS	CRIES EASILY	EAR INFECTIONS	DIAPER RASH	DIZZINESS

If you have circled any of the above conditions, please elaborate on their treatment.

_____________________________________________________________

Has your child ever had any diagnostic testing? (EEG,EKG, blood work, x-ray)

_____________________________________________________________

Medications (circle any meds that your child uses regularly)

Tylenol

Aspirin

Advil

Decongestant

Ventolin

Antibiotics

Corticosteroids

Anti-histamines

Supplements

SUPPLEMENTS	REASON FOR USE	LENGTH OF USE
1.
2.
3.

FAMILY HISTORY

CIRCLE ANY OF THE FOLLOWING CONDITIONS THAT RUN IN YOUR FAMILY.　

HEART DISEASE	KIDNEY DISEASE	COLITIS	STROKE	ALLERGIES	DRUG ABUSE
ARTHRITIS	TB	CHRON’S	ANEMIA	MIGRAINES	MS
MENTAL ILLNESS	ASTHMA	CANCER	HIGH BLOOD PRESSURE	EPILEPSY	DEMENTIA
DIABETES	LEUKEMIA	ECZEMA	ALCOHOLISM	PARKINSON’S DISEASE	OSTEOPOR-OSIS

IMMUNIZATION HISTORY

Please circle the immunizations your child has had and note any adverse reactions:

MMR

Hib

DTaP

Rotavirus

Pneumococcal

Meningococcal

Influenza (INCLUDING H1N1)

CHICKEN POX/varicela

Polio

HPV (girls only)

Was there any variation in the vaccine schedule or was it routine?

DIETARY HISTORY

Was your child breastfed? If yes, for how long? _______________________

What formula was used if any? (milk based, soy based, hypoallergenic formula, etc.) _____

__________________________________________________________________

At what age were solid foods introduced? ____________________________________

What was your child's first solid food? ______________________________________

At what age were milk and milk products introduced? ___________________________

Any known food sensitivities or allergies? ___________________________________

Please describe a typical day of eating for your child:

MEAL	SAMPLE
BREAKFAST
LUNCH
DINNER
SNACKS

Thank you for taking the time to fill out this form acurately!

SUPPLEMENTS/MEDICATIONS TAKEN DURING PREGNANCY	ILLNESSES EXPERIENCED DURING PREGNANCY
	GESTATIONAL DIABETES
	PREECLAMPSIA
	MEASLES
	MISCARRIGES
	TOXEMIA
	PREMATURE LABOR
	HERPES/OTHER VIRAL ILLNESSES
	EDEMA
	BLEEDING