Pediatric Intake Form

PEDIATRIC INTAKE FORM

Date: ______Name: ______Gender: M / F

Date of birth: ______Parent/ Legal Guardian Name: ______

Email Address: ______Address: ______

Health Card Number: ______Adopted: Y / N

Phone (Home): ______(Work): ______(Cell): ______

Medical Doctor: ______Height & Weight: ______

Child lives with Parents? Y / N If no, explain ______

Emergency Contact:

NAME:______

ADDRESS:______

PHONE: ______

Who Referred You to this Clinic? ______

PRIMARY HEALTH CONCERNS

1. ______

2. ______

3. ______

4. ______

Others: ______

How did these conditions develop? Are there any specific events (surgeries, drug reactions, accidents, food, etc.) that you can identify that caused or have aggravated these conditions? What has improved these conditions?

MEDICATIONS: (Past or current):

Prescribed medications:

/ Purpose / Dose / Side Effects
Supplements(vitamins & minerals, herbs, homeopathics)
Current / Past

ALLERGIES or SENSITIVITIES

Allergy to: / Past / Current / Time of Onset
Medications
Supplements
Foods
Environment

PAST SURGERIES/ HOSPITALIZATIONS

Surgery/hospitalization / Dates / Hospital/Clinic / Reason
1.
2.
3.

ILLNESSES/ Review of Systems

(Please put an N if your child has the condition now, P for in the past, B for both)

Chicken Pox ______Diphtheria ______Rubella (German/3day)_____Measles (2 wk) ______Mumps ______Polio ______Whooping Cough ____ Mononucleosis ______Roseola ______Headache ____ Scarlet Fever ______Rheumatic Fever_____ Severe Head Injury ______Dizziness ______Cradle Cap____ Seizures ______Vision Problems _____ Frequent Runny Nose ______Nosebleeds ______Earaches _____

Strep Throat ______Tonsillitis ______Recurring Ear Infections _____Asthma ______Bronchitis ____ Croup ______Pneumonia ______Coughing/ Wheezing ______Pleurisy ______Heart murmur_ High Blood Pressure __ Frequent infections __ Influenza ______Fevers ______Acne ______Ulcers ______Freq. headaches ____ Herpes (oral) ______Eczema ______Constipation __

Indigestion/ Gas _____Diarrhea ______Colitis ______Vomiting ______Jaundice _____

Bed wetting ______Bladder infection ____ Meningitis ______Encephalitis ______MS ______Paralysis ______Cerebral Palsy______Anemia ______Cancer ______Diabetes _____ Hypoglycemia ______Hypothyroid ______Hyperthyroid ______Anxiety ______Fears______

Hives ______Chronic Rash ______Hair loss ______Excessive Fatigue ____Nervous _____

Sore Throats ______Frequent Colds _____Burning urination ______Nightmares ______Cries easily ___

Talks in sleep ______Bruises easily ______Dizzy spells ______Cough ______Wheezing ____

Hearing Loss ______Stomach aches _____Bleeding gums ______Body odour______Bad breath ___

Motion sickness ____Sensitive to light _____Other (specify) ______

PRENATAL HISTORY – mother’s health during pregnancy

Has the child’s mother had any occurrences of miscarriages, stillborns, abortions, or difficulty conceiving? Y / N

If yes, describe: ______

Please place a check mark beside any of the following pregnancy complications, if they occurred:

Nausea ______Vomiting ______Hypertension ______Diabetes ______Pre-eclampsia______Bleeding ______

Describe mother’s diet during pregnancy, any food cravings? ______

______

What medications/supplements did the mother take during pregnancy? ______

______

Did the mother smoke prior to or while pregnant? Y / NIf yes, what amount: ______

Did the mother use drugs or alcohol? Y / N If yes, type and amount: ______

While pregnant, did the mother have any medical or emotional difficulties? Describe: ______

Did the mother have any infections (e.g. colds/flus/vaginal infections etc.) during pregnancy? If yes, what type?______

Length of pregnancy (weeks): ______

Length of labour: ______Induced Y / N Caesarean Y / N Interventions used (forceps, vacuum)Y / N

Describe any complications for the mother or the baby during delivery or after the birth: ______

Baby’s birth weight: ______Baby’s birth length: ______

PRENATAL HISTORY-Father’s health before conception

Did the father smoke prior to or during pregnancy? Y / NDid the father use drugs or alcohol preconception?Y / N

If yes, type and amount: ______

In what way was the father involved in the pregnancy?______

DIET HISTORY:

If breast-fed, how long? ______If formula fed, how long? ______

Age solids foods introduced: ______Any adverse reactions? ______

How is your child’s appetite in general? ______Is your child a picky eater? Y / N

List the primary foods included in your child’s diet: ______

______

List the foods you exclude from your child’s diet:______

List any food cravings: ______Amount of liquid your child drinks each day ______

IMMUNIZATION RECORD

Vaccination / Date / Adverse Reactions
Diphtheria, Tetanus, Pertussis DPT)
Oral Polio Vaccine (OPV)
Measles, Mumps, Rubella (MMR)
Hepatitis
Hib
Influenza
Meningoc.
Varivax
Flu

DENTAL HISTORY

Was the process of teething difficult for your child?Y / NDescribe,______

Has your child been to the dentist? Y / N Describe any dental work done: ______

Does your child have any metal fillings? Y / N

DEVELOPMENTAL HISTORY

Please note the age at which the following behaviours took place:

Weaned:
______/ Sat Alone: ______/ Crawled: ______/ First Teeth: ______/ Walked: ______

Compared to others in the family, child’s development was: Slow ______Average ______Fast ______

In what ways: ______

BOWEL/URINARY HABITS

Frequency of stool: ______Does your child have pain on passing stool? ______

Have you noticed any abnormalities in your child’s stools? (colour changes, consistency, undigested foods) ______

Does your child experience any urinary symptoms? ______

SLEEP HISTORY

Does your child have trouble falling asleep? Y / N

Please check if your child experiences any of the following while sleeping:

Uninterrupted ______Wakes often/ Restless ______Nightmares ______Wakes for reassurance ______

Wakes for food ______Calm ______Awakes well rested ____ Awakes tired/irritable ______Night Sweats______

Temperature of your child while sleeping is generally (circle): HOT COLD NEITHER

If nightmares, what is the theme? ______What position does your child sleep in? ______

FAMILY HEALTH HISTORY

Mother / Father / Siblings
Age
If Deceased, age at death & cause of death?

Please place a check mark beside the conditions that have occurred among the child’s relatives

Allergies ______Asthma ______Anemia ______Arthritis ______Alcoholism______Bleeding tendency ____ Blindness ______Cancer ______Deafness ______Diabetes ______Depression______Eczema ______Glaucoma ______Gout ______Heart disease ______High blood pressure __ Hypothyroid ______Hyperthyroid ______Kidney disease ______Mental illness ______Mental retardation ___ Migraines ______Multiple Sclerosis ____ Muscular Dystrophy __ Nervousness ______Perceptual motor disorder ______Seizure/epilepsy _____ Stroke ______Tuberculosis ______Anxiety ______Glaucoma ______Smoking ______Other (specify): ______

Thank you for taking the time to fill out this intake form. Full completion ensures better healthcare for your child!

We look forward to working with you and your family on your path to wellness.

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