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: ______
______
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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: ______
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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? ______
______
______
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Please indicate any conditions that exist in the child's birth mother or father or their families.
Condition / Mother / Father / Brothers / Sisters / Grandparents / OthersAlcoholism
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
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