PEDIATRIC INTAKE FORM (Birth 12 Years)

Dr. Cindy Quach & Associates

PEDIATRIC INTAKE FORM (Birth – 12 years)Date:______

To be completed by parent/guardian. Please return completed form to clinic reception at least 24 hours prior to your appointment. You may fax, email, or drop it off at the clinic.

Patient Information

Name: ______Personal Health Number: ______

Age: ______

Date of Birth (MM/DD/YY): ______

Sex: Male Female

Current Height and Weight: ______

Ethnicity: ______

Address: ______

Phone number: ______

May we leave messages relating to your child’s visit? YES NO

Health Care Provider Information

Medical DoctorPediatrician

Name ______Name______

Address ______Address ______

______

Phone number ______Phone number ______

Fax number ______Fax number ______

Other Health Care Providers

Name ______Name ______

Address ______Address ______

______

Phone number ______Phone number ______

Fax number ______Fax number ______

Name of person filling out this form and your relationship to child: ______

Parent/Guardian InformationEmergency Contact

Name ______Name ______

Address ______Address ______

______

Phone number (H) ______Phone number (H) ______

(W) ______(W) ______

(cell) ______(cell) ______

Email address of Parent/Guardian:

______

Relationship to child ______Relationship to child ______

Whom does the child live with? ______

How did you hear about our clinic?: ______

Referred by: ______

What are your child’s health concerns (in order of importance)? How long has your child experienced these problems?

1. ______

2. ______

3. ______

4. ______

5. ______

Medical history

How would you describe your child’s general state of health? Excellent Good Fair Poor

Please list any serious illnesses, injuries, hospitalizations, accidents, or surgeries with approximate dates:

Event / When / Treatments

Please indicate if your child has ever had any of the following:

[ ] Chicken Pox[ ] Yeast infection[ ] Eczema[ ] Roseola

[ ] Measles[ ] Strep throat[ ] Scarlet fever [ ] Head lice

[ ] Rubella (German measles)[ ] Ear infections (#______)[ ] Mononucleosis[ ] Impetigo

[ ] Mumps[ ] Frequent colds (#/yr ____) [ ] Epiglotitis[ ] Other

[ ] Whooping cough[ ] Asthma[ ] Croup______

Please indicate what immunizations your child has had, and the date:

[ ] DPT (diptheria, pertussis, tetanus) ______[ ] Polio ______

[ ] Tetanus booster ______[ ] Hepatitis A ______

[ ] MMR (measles, mumps, rubella) ______[ ] Hepatitis B ______

[ ] Haemophilus influenza B ______[ ] Other ______

[ ] “Flu” ______

Were there any adverse reactions to the immunizations?

______

Does your child have any drug allergies?

______

How many times has your child been treated with antibiotics? ______

For what reason were antibiotics prescribed? ______

Any changes in the health (physical/emotional) seen after the antibiotics? ______

______

Please list all currentmedications (prescription, over-the-counter, vitamins, herbs, etc.) and amounts

List of medications / Dosage/Amount / Reason for taking / Duration of use

Please list all past prescriptionmedications and amounts

List of medications / Dosage/Amount / Reason for taking / Duration of use

Please list all current and past treatments (chiropractic, acupuncture, physical therapy, psychotherapy, massage etc.). For what reasons were your child receiving these treatments?

List of treatments / Reason for treatment / Duration of treatment (years)

Pre-natal health

What were the age and general health of the parents at the time of the child’s conception?

Mother (Age )ExcellentGood Fair Poor Unknown

Father (Age )ExcellentGood Fair Poor Unknown

Please list any health problems of the parents at conception:

Mother: ______

Father: ______

What was the general health of the mother during the pregnancy?

ExcellentGood FairPoor Unknown

Please provide a general description of the mother’s diet during pregnancy

Breakfast: ______

Lunch: ______

Dinner: ______

Beverages: ______

Snacks: ______

Cravings: ______

How much weight did the mother gain during pregnancy?

First trimester: ______

Second trimester: ______

Third trimester: ______

Did the mother receive prenatal medical care? YES NO

By whom? ______

Did the mother experience any of the following during pregnancy?:

[ ] Infections[ ] Physical/emotional trauma

[ ] Bleeding[ ] Cold/flu

[ ] Diabetes[ ] Significant stress

[ ] High blood pressure[ ] Travel

[ ] Thyroid problems[ ] Chemical exposure

[ ] Excessive nausea/vomiting[ ] Yeast infection

[ ] Depression[ ] Other ______

What was the treatment given to the mother for any of the above?

______

Did the mother use any of the following during pregnancy?

[ ] Tobacco

[ ] Alcohol

[ ] Recreational drugs

[ ] Prescription medications ______

For what purpose? ______

[ ] Over-the-counter medications ______

For what purpose? ______

[ ] Supplements ______

For what purpose? ______

[ ] Other ______

Has the mother ever had a miscarriage? YES NO # of times ______

Has the mother ever had an abortion? YES NO # of times ______

Birth history

Length of term: [ ] Full[ ] Premature (# weeks) ______[ ] Late (# weeks) ______

Length of labour: ______

Complications during labour: [ ] Wrapped cord [ ] Breech [ ] Fetal distress [ ] Other ______Interventions during labour: [ ] Epidural [ ] Oxytoxin [ ] Episiotomy [ ] Other ______

Type of birth: [ ] Vaginal [ ] C-section [ ] Induced [ ] Forceps [ ] Vacuum [ ] Anesthesia

Who delivered the baby? ______

Where was the baby delivered? [ ] Hospital [ ] Home [ ] Water-birth [ ] Other ______

Infant’s weight at birth ______

Infant’s length at birth ______

Infant’s APGAR score at birth ______

Did the infant experience any of the following at or shortly after birth?

[ ] Jaundice[ ] Birth injuries ______

[ ] Blue skin (cyanosis) [ ] Birth defects ______

[ ] Seizures[ ] Other ______

Diet of infant

How was your infant fed, and for how long?

[ ] Breast fed ______

[ ] Formula ______

[ ] Milk (type of milk) ______

[ ] Other ______

Did your infant experience any adverse reactions from any of the above feeding methods?

______

What foods were introduced before 6 months? (Please list approximate month)

______

What foods were introduced at 6 –12 months? (Please list approximate month)

______

Were there any reactions to the foods introduced? (Describe)

______

Does your child have any food allergies or intolerances?

______

Does your child have any dietary restrictions (religious, vegetarian / vegan, etc.)?

______

Describe your child’s typical daily diet:

Breakfast ______

______

Lunch ______

______

Dinner ______

______

Snacks ______

______

Beverages ______

______

Health and Development

How was your child’s health in the first year?Excellent Good Fair Poor Unknown

HeightWeight

At birth ______At birth ______

At 1 year ______At 1 year ______

At 2 years ______At 2 years ______

At 5 years ______At 5 years ______

At 10 years ______At 10 years ______

Any period of rapid weight gain or loss? YES NO

At what age did your child first Sit up ______Crawl ______Walk ______Talk ______

How many hours of sleep per night does your child currently obtain? ______

Child’s bedtime ______Child’s wake-up time ______

Does your child experience any of the following sleep problems?

[ ] Problems falling asleep[ ] Bedwetting

[ ] Sleepwalking[ ] Grinding of teeth

[ ] Frequent nightmares [ ] Other ______

How would you describe your child’s temperament? ______

______

Does the child have any difficulties at school? (Academically or socially) ____________

______

Family history

Please indicate if any of the child’s family members (e.g. mother, father, maternal/paternal grandparents, siblings, aunts, and uncles) has ever encountered any of the following health concerns. Include only blood relatives.

Health Concern / Family Relative / Health Concern / Family Relative
Alcoholism / High blood pressure
Allergies / Infertility
Alzheimer’s disease / Intestinal disease
Arthritis / Learning disability
Asthma / Mental illness
Cancer (indicate type) / Migraine headaches
Diabetes / Neurological disorders
Drug addiction / Obesity
Eating disorder / Osteoporosis
Genetic disorder / Stroke
Glaucoma/cataracts / Suicide
Heart disease / Liver disease
Kidney disease / Other

 I don’t know this child’s family medical history

# of siblings:______Child’s birth order: ______

Environment

Is the child in [ ] school [ ] daycare [ ] home care [ ] other ______

Who is the child’s primary caregiver/supervisor during the day? ______

What are your child’s extracurricular activities (Please list)

______

What are your child’s favorite activities? ______

______

How many hours per week of television does your child watch? ______

How many hours per week does your child play video games? ______

How many hours per week is your child on the computer? ______

How many hours per week does your child read? ______

Are there animals in the home? YES (Please list) NO ______

Does your child have any allergies to the following?

[ ] Cigarette smoke[ ] Chemicals

[ ] Dust [ ] Molds

[ ] Pollen[ ] Pesticides

[ ] Animal dander[ ] Other ______

How would you describe the emotional climate of the child’s home?

______

Is there anything that you feel is important that has not been covered?

______

Review of Systems (Please circle if your child has experienced any of the following in the past/present)

General: headache fever/chills fatigue/weakness dizziness fainting

Skin: rashes eczema psoriasis dryness/moistness night sweats itching colour change

Eye: pain itching tearing dryness redness double vision blurring discharge

Ears: pain itching discharge impaired hearing infection obstruction redness

Nose: pain itching stuffiness runny nose nosebleed sinus problems hay fever

Mouth: cavities sore tongue sore throat tonsillitis tonsillectomy no taste no saliva

Neck: pain stiffness lumps swollen glands swollen thyroid

Respiratory: cough sputum spitting up blood wheezing shortness of breath bronchitis

Cardiovascular: blue skin rapid/slow heart rate rheumatic fever chest pain hear murmurs

Gastrointestinal: nausea vomiting diarrhea constipation abdominal pain excessive gas

Urinary: pain on urination blood in urine increased frequency change in colour discharge

Male reproductive: hernia testicular mass testicular pain penile discharge

Female reproductive: vaginal itching vaginal discharge

Musculoskeletal/Neurological: joint pain/redness/swelling speech problems seizures tingling

Peripheral vascular: leg cramps deep leg pain cold hands/feet numbness

Blood/Endocrine: easy bruising easy bleeding excessive thirst/hunger excessive sweat

#101-8501 162 Street, Surrey, BC

Tel: (778) 218-3111 Fax: (778) 218-3129

Email: