New England Holistic Health Center

155 Sycamore Street, Glastonbury, CT 06033 Tel: (860) 659-3553 Fax: (860) 659-0744

PEDIATRIC INTAKE FORM

Patient Name: Gender: M F Date:

______

DOB: ______Grade in School: ______

Mother's Name and Occupation: ______

Father's Name and Occupation: ______

Parents are (circle): Married Separated Divorced Living Together Other: ______

Reason for Office Visit: ______

Has child been seen by any other doctor(s) for this complaint? Yes No Past

Regular Pediatrician name and city located in: ______

Last time you had blood work done and with what physician: ______

______

List all surgeries & hospitalizations, including date occurred:

1) ______4) ______

2) ______5) ______

3) ______6) ______

List all medicines (from drugstore or prescription) child is on now:

1) ______4) ______

2) ______5) ______

3) ______6) ______

List all supplements/homeopathics child is taking:

1) ______4) ______

2) ______5) ______

3) ______6) ______

Any known allergies to food, drugs, environment, animals: ______

______

Past Medical History

Indicate Y (yes) if the child gets the problem regularly; N (no) if the child never had the problem; and P (past) if the child had the problem in the past, but not recently. Please circle the correct one for your child.

Ear Infections: Y N P If has had, how many total: ______

Colds: Y N P If has had, how many total: ______

Strep Throat: Y N P If has had, how many total: ______

Hearing Tests Normal: Yes No Not Tested Vision Tests Normal: Yes No Not Tested

Speech Impediments: Yes No Past Learning Impediments: Yes No Past

Vaccination History

YES, had had; NO, has not; SOME, did not finish all shots:

MMR: Yes No Some DPT: Yes No Some Hep B: Yes No Some

Hib: Yes No Some Chicken Pox: Yes No Some Polio: Yes No Some

Other: ______

Any reactions to vaccinations? If so, please explain: ______

______

Mother's Pregnancy History

Age at conception: ______Did she have other children already? Y N How many: ______

Smoking: Y N Alcohol/Recreational Drugs Y N Coffee: Y N

Nausea/Vomiting: Y N Emotional Stress: Y N

Preeclampsia: Y N Gestational Diabetes: Y N

Length of Labor: ______Vaginal Birth or C-Section (circle one)

Traumatic Birth: Y N If yes, please explain: ______

______

Health History of Child

Weight at birth: ______Health of baby at birth: ______

Child breastfed: Y N For how long: ______When put on formula: ______

What formula was used: ______When was child put on solid food: ______

When did child walk: ______Talk: ______Develop Teeth: ______

Health History of Child (Continued)

Indicate Y (yes) if the child had any of the following; N (no) if the child did not have any of the following; P (past) if the child had any in the past:

Jaundice as baby: Y N P Colic: Y N P

Cradle Cap: Y N P Anemia: Y N P

Eczema or Psoriasis: Y N P Asthma/Wheezing: Y N P

Diarrhea: Y N P Warts: Y N P

Constipation: Y N P Nightmares: Y N P

Finicky Eating: Y N P Bed-wetting: Y N P

Poor Teeth: Y N P Tantrums: Y N P

Chronic Sniffles: Y N P Disobedient: Y N P

Bad Foot Odor: Y N P Fears/Phobia: Y N P

Very Sweaty Baby/Child: Y N P Diaper Rash; Y N P

Hyperactivity: Y N P Early Puberty: Y N P

Growing Pains: Y N P Stomach Aches: Y N P

Any particular household stressors child has witnessed or gone through:

1) ______2) ______

3) ______4) ______

Toxin Exposure

Has the child ever lived near a refinery, polluted area or in a home with leaded paint? If so, what sort of pollution were you exposed to? ______

Has the child ever lived in a house that had new carpeting, paint, cabinets or any other refurbishing that seemed to affect their health at all? ______

Does the child seem particularly sensitive to perfumes, gasoline or other vapors? ______

Do you spray pesticides, herbicides or other chemicals around your home? ______

______

Typical Day's Diet

Breakfast: ______

Lunch: ______

Dinner: ______

Snacks: ______

Drinks: Water: ______Soda: ______

Dairy: ______Soy: ______Other: ______

How often do you and your child eat out weekly? What restaurants do you frequent? ______

______

Please indicate any conditions that exist in the child's birth mother or father or their families.

Condition / Mother / Father / Brothers / Sisters / Grandparents / Others
Alcoholism
Allergies
Anemia
Anorexia/Bulimia
Arthritis
Asthma
Birth Defects
Bleeding Disorder
Cancer/Leukemia
Depression
Diabetes
Drug Abuse
Emphysema
Epilepsy or Seizures
Gallbladder Disease
Glaucoma Cataracts
Gout
Heart Attack
Heart Disease/
Circulatory problems
Hepatitis or Liver Disease
High Blood Pressure
Hypoglycemia
Kidney or Bladder Disease
Kidney Stones
Malaria
Mental Illness
Migraine Headaches
Mononucleosis
Multiple Sclerosis
Muscular Dystrophy
Obesity
Osteoporosis
Physical Abuse
Rheumatic Fever
Sexual Abuse
Scoliosis (curvature of the spine)
Stroke
Suicide
Thyroid Problems, Goiter
Tuberculosis (TB)
Ulcers
Sexually Transmitted Diseases
Other

Thank you for taking the time to fill out this questionnaire