Dr. Liam Fardy's Intake Form

Dr. Liam Fardy's Intake Form

This will take around 15 minutes to complete. All information is sent directly to Dr. Fardy and is confidential.
Child's First Name*
Child's Last Name*
Date of Birth*

MonthDayYear
Date
Parent/Legal Guardian's Phone number*
Father's Name*
Mother's Name*
Preferred Pharmacy*
Allergies? [Drug, Food, Environmental ]*

Were there any concerns during your pregnancy?*
Was there any exposure to smoke, cannabis, alcohol, or any other substances during pregnancy? If yes, please explain.*

YesNoOther
Was {childsFirstname} born at term?*

YesNo
Where was {childsFirstname} born?*
What was {childsFirstname}'s weight at birth?*
Was there any issues shortly after {childsFirstname}'s birth? Ex. jaundice, infections, etc*

Medications
Does {childsFirstname} take any medications? [This includes vitamins and supplements. Please list the dose and frequency if you know it.*
Has {childsFirstname} had all their routine vaccinations? If no, please explain.*

YesNoOther

Developmental History
At what age did {childsFirstname} do the following?
Roll Over*
Sit up alone*
Walk alone*
Say First Words*
Join Words Together*
Dress Themselves*
Has {childsFirstname} developed a skill and then lost the ability to perform that skill? Ex. able to speak in two-word sentences and now unable to do so? If yes, please explain.*

YesNo

Social History
Where is {childsFirstname} currently living? [Town/City]*
Please list everyone living in their house with their age, education level, and their occupation.*
What school/preschool/daycare does {childsFirstname} go to?*
What grade is {childsFirstname} in?*
Is {childsFirstname} in the prescribed or alternate curriculum?*
Does {childsFirstname} have academic accommodations in place? Ex. Extra time for tests. Chromebook, etc? If yes, please explain.*

YesNoOther
Has {childsFirstname} experienced bullying?*

YesNo
Do you ever worry about if {childsFirstname} will ever have enough access to food?*

YesNo
Has your family ever been involved with the Department of Children, Seniors and Social Development [CSSD]?*

YesNo

Health History