Pediatric Intake form with Consent

Joyspath

PEDIATRIC INTAKE FORM FOR NEW PATIENTS
Today's Date

DayMonthYear
Date
Child's Personal Information
Child's Full Name*

First NameMiddle NameLast Name
Gender
Age
Birthdate

DayMonthYear
Ethnic / Religious Background
Height
In Feet + Inches or Centimeters
Weight
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Parent or Legal Guardian's Name

First NameMiddle NameLast Name
Child's Medical Doctor / Pediatrician
Primary Health Concerns
(Please list inorder of most importance)

Medications (Past or Current)

Rows	Prescribed Medications	Purpose	Dose	Side Effects
1
2
3
4
5
6

Over-the-counter medications (Current & Past)
Supplements (vitamins & minerals, herbs, homeopathics, other supplements. - Current & Past)

Allergies or Sensitivities

Rows	Past	Current	Time of Onset
Medications
Supplements
Foods
Environment

Past Surgeries / Hospitalizations / Interventions (ex. circumcision)

Rows	Dates	Hospital / Clinic	Reason
1
2
3
4

Illnesses / Review of System

Rows	Now	Past	Both
Chicken Pox
Diphtheria
Rubella (german/3day) Measles (2 wk)
Mumps
Polio
Whooping Cough
Mononucleosis
Roseola
Rheumatic Fever
Scarlet Fever
Cradle Cap
Headaches
Dizziness
Severe head injury
Seizures
Vision Problems
Frequent Runny Nose
Nose bleeds
Recurring Ear Infections
Earaches
Strep Throat
Tonsillitis
Asthma
Bronchitis
Coughing/ Wheezing
Croup
Pneumonia
Pleurisy
Heart murmur
High Blood Pressure
Frequent infections
Influenza
Fevers
Acne
Ulcers
Hives/ Rashes
Herpes (oral)
Eczema
Indigestion/ Gas
Constipation
Diarrhea
Colitis
Vomiting
Jaundice
Bed wetting
Bladder infection
Meningitis
Encephalitis
Cerebral Palsy
Paralysis
MS
Anemia
Cancer
Diabetes
Hypoglycemia
Hypothyroid
Hyperthyroid
Anxiety
Fears

If you have checked any of the above, please fill out the following

Rows	Condition	How many times and when?	How long each time?
1
2
3
4

Prenatal History

Mother's Health During Pregnancy
Has the child’s mother had any occurrences of miscarriages, stillborns or abortions?
Yes No If Yes, please describe.
Has the child’s mother ever had any difficulty conceiving (e.g. infertility, ectopic pregnancies):
Yes No If Yes, please describe.
NauseaVomitingHypertensionDiabetesPre-eclampsiaBleedingOther
If you checked any of the above, describe the extent of the condition and what was done to treat it
YesNo
Mother's age at child's birth
Total children
Genders
Ages
How many pounds did the mother gain during the pregnancy?
Describe mother’s diet during pregnancy, any food cravings?
What medications/supplements did the mother take during pregnancy?
Did mother exercise during pregnancy? How much and what type?
Did the mother smoke while pregnant? Yes
Did the mother smoke before conception? Yes No If Yes, what amount?
Did the mother use drugs or alcohol? Yes No If Yes, type and amount.
While pregnant, did the mother have any medical or emotional difficulties? (e.g. surgery, hypertension, medication) Yes No If Yes, please describe.
Where did the mother spend most of her time during pregnancy? Describe the environmental conditions
Did the mother travel during pregnancy? Yes No If Yes, where?
Did the mother have any infections (e.g. colds/flus/vaginal infections etc.) during pregnancy?
Yes No If Yes, please
Perinatal / Neonatal History
HospitalHomeClinicOther
Delivered by whom?
Length of Pregnancy (weeks)
Was pregnancy easy? Difficult? Yes No If Yes, please describe.
Length of Labor
InducedCaesarianInterventions Used ( forceps / vaccum / c-section)Other
Length of hospitalization for mother
Length of hospitalization for baby
Describe any physical or emotional complications with the delivery
Did breast feeding begin immediately? Type option 1 Type option 2 If Yes, please describe.
SeizureVitamin K AdministeredRespiratory distressAntibiotic Eye DropsJaundiceCongenital AbnormalitiesProblems with feedingRespiratory Abnormalities
Feeding / Diet History
Describe any complications for the mother or the baby after the birth:
Baby's Birth weight Baby’s birth length
Head Circumference APGAR Scores
If Breast fed, how long? Was it difficult or easy? Easy Difficult
Approximate Feeding Schedule
If formula fed, how long?
Combined with breast milk? Yes No If yes, describe
Types of formula and any adverse reactions?
Age solid foods introduced
List foods and in what order they were introduced:

Please indicate if there were any adverse reactions to any newly introduced foods:

Rows	Food Introduced	Colic	Bloating	Gas	Change in bowel movt’s (diarrhea /constipation)	Nausea/Vomiting	Rashes
1
2
3
4

List any foods your child craves (include sweet, salty, fatty, etc. foods):
How many meals does your child generally eat each day?
How is your child’s appetite in general?
YesNo
List the primary foods included in your child’s diet
Amount of liquid your child drinks each day
Amount plain water
Describe other types
Are you satisfied with your child’s diet? Why or why not?
Are you satisfied with your child’s diet? Why or why not?
YesNo
If yes, explain

Please place a check mark if any of the following conditions are experienced by your child regularly

Rows	Colic	Bloating	Change in bowel movt's (diarrhea /constipation)	Nausea / Vomitting	Rashes
When
How Often
Why (if you know)

YesNo

Immunization Record

Rows	Date	Adverse Reactions
Diphtheria, Tetanus, Pertussis DPT)
Oral Polio Vaccine (OPV)
Measles, Mumps, Rubella (MMR)
Hepatitis
Hib
Influenza
Meningococcemia
Varivax
Flu

Has your child been out of the country? Where? When?
Developmental History

Please note the age at which the following behaviors took place

Rows	Age
Weaned
Dry during day
Dry during night
Toilet trained
Fed self
Spoke words
Spoke sentences
Sat alone
Crawled
Took first steps
Dressed self
Tied shoe laces
Rode two-wheeled bike
First teeth

SlowAverageFast
Dental History
Was the process of teething difficult for your child?   Yes   No    Please describe.
Has your child been to the dentist? Yes   No
Any dental work done?   Please describe.
Describe your child’s oral hygiene practice?
Is your child’s toothpaste fluoridated?   Yes   No
Vision History
Has your child’s eyes been checked?  Yes   No
Does your child wear glasses?Yes   No
Describe any vision problems:   Please describe.
Bowel / Urinary Habits
Frequency of stool  Times per day Times per week
What does the stool look like?
Does your child have pain on passing stool?
Have you noticed any abnormalities in your child’s stools? (colour changes, consistency, undigested foods)  Please describe.
Does your child experience any urinary symptoms?  Please describe.
Sleep History
Does your child have trouble falling asleep? Yes No
How would you rate your child’s sleep?

1

1 is Very Poor, 1 is Excellent
UninterruptedWakes often / restlessNightmaresWakes for reassuranceWakes for foodCalmAwakes well restedAwakes tired / irritableNight sweats
Temperature of your child while sleeping is generally   Hot   Cold   Neither
If nightmares, what is the theme?
What position does your child sleep in?
Social History / Home Environment
Who takes care of the child primarily?
Does the child have a babysitter/nanny?   Yes   No
Does the child go to daycare?  Yes   No
How are problem behaviors, generally handled?
What are the family’s favorite activities?
Does your child get along with other children?   Yes   No  Explain
Does your child get along with adults?  Yes   No
What does your child do with unstructured time?
How much time does your child spend in front of the TV/Computer?
What is your child’s favourite book?
Does the child have a favourite toy/blanket?  Yes   No   Describe
What extra activities is your child involved in?
How does your child keep his/her room?
Describe neighborhood (e.g. parks, other children, safety):
Describe your child’s temperament:
Does she/he prefer to play alone or with others?
Behavior / Emotions
AffectionateGenerousSharesConfidentListens to reasonCooperativeFrustrated easilyIrritableMoodyRestlessAggressiveAngryImpulsiveDefiantSelfishSadCrying spellsHopelessDepressionLazyShy/Timidlack of self-confidenceCritical of selfCritical of othersSuspiciousTalks backSlow movingShort attention spanLearning problemsMemory difficultyMental confusionMakes many mistakesSpeech problemsLow self-esteemAnxietySeparation anxietyAttachment to dollsAvoids adultsLonerlikes companyImaginary friendsHallucinationsNightmaresDizzinessStomachachesBedwettingSoilingOften sickTics / TwitchingBlinking / JerkingTeeth grindingThumb suckingMessyClumsySensitive to noiseOrganizedCareless/RecklessUnsafe behaviorsBullies/ThreatensBizarre behaviorSets firesHurts animalsDestructiveStealsSuicidal threatSuicidal attemptsHead bangingSexual addictionCyber addictionDrug dependenceLies frequently
Anger
What makes your child angry?
Does your child get angry often/easily?
Does your child experience uncontrollable rage?
Does your child have difficulty expressing anger?
Sadness
What makes your child sad?
Does your child cry when sad?
Does your child cry often/easily?
Grief
List major experiences of grief/loss in your child’s life
Fears
What fears does your child have?

Listed below are factors that may or may not influence your child’s state of being. Please indicate if the factors makes your child better, worse or unaffected.

Rows	Is your child better, worse or unaffected?
Autumn
Winter
Spring
Summer
Cold
Heat
Dampness
Storms
Wind
Sun
Moonlight
Open-air
Confined (stuffy) air
Ocean Seashore
Mountains
Change of weather
Upon rising
Morning
Afternoon
Evening
Night
Touch
Being consoled
Left alone
Traveling
Physical exertion

Other factors, please indicate:
Family History

Mother's Side

Rows	Mother	Father	Grandfather	Grandmother	Siblings
Age or If deceased: at what age?
Cause of death?

Father's Side

Rows	Mother	Father	Grandfather	Grandmother	Siblings
Age or If deceased: at what age?
Cause of death?

Please check the conditions if they have occurred among the child’s relatives and note which relatives has / had them.

Rows	Has the conditions occurred among child's relatives?	Who has / had the condition?
Allergies
Asthma
Anemia
Arthritis
Bleeding tendency
Blindness
Cancer
Deafness
Diabetes
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

Other family conditions, please specify (if applicable)

CONSENT FORM
Homeopathy is a system of medicine founded by Dr. Samuel Hahnemann (1755-1843) of Germany. It is based on the principle that “like cures like”. In practice, this means that a medicine capable of producing certain effects when taken by a healthy human being is capable of curing any illness that displays similar effects.

Another fundamental principle of Homeopathy is that it treats the patient as a whole and as an individual. There is no medicine for a particular disease. There is a medicine for the person suffering from the disease. The homeopath takes into consideration all the symptoms that distinguish a person as an individual. This includes details of the patient’s past and family history, temperament, dietary habits, sleep, etc.

1. I fully understand what has been explained to me in regards to:
- The nature of homeopathic medicines (remedies)
- The safety of homeopathic remedies and possibility of short-term physical or mental aggravations
2. I acknowledge and declare that:
- The decision to seek homeopathic treatment is solely my decision
- I have not been advised at any time to stop seeking allopathic treatment (medical doctor or MD), and that standard medical treatment must be obtained from a medical doctor
- I accept full responsibility for fees incurred during care and treatment, and agree that payment is due when services are rendered (at the end of each visit), unless prior arrangements have been made. This includes a charge of the whole appointment fee, for missed appointments unless 24 hours notice has been given.
- I will clarify any questions I have about my treatment with my homeopathic practitioner.
- Joy Burlton is currently registered and in good standing with the College of Homoepaths of Ontario reg # 15258
All information disclosed is confidential and remains protected according to the Privacy Act of Ontario.
I, First Name* Last Name* , Parent / Guardian of First Name* Last Name* have read, understood and acknowledge the above statements.

Witness : First Name* Last Name*
Parent / Guardian's Signature*

Clear
Date Signed*

DayMonthYear
Date
Should be Empty:

Joyspath

Child's Personal Information

Prenatal History

Perinatal / Neonatal History

Feeding / Diet History

Developmental History

Dental History

Vision History

Bowel / Urinary Habits

Sleep History

Social History / Home Environment

Behavior / Emotions

Family History

CONSENT FORM