CHILD New Patient Intake Form

CHILD New Patient Intake Form

For ages 12 and under
Email*
example@example.com
Child's Name*

First Name Last Name
Parent's Name*

First Name Last Name
Address*

Street Address

Street Address Line 2

City Province

Postal
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Date of Birth*

MonthDay Year
Date
Age*
Sex at birth*

Health Information
Family Doctor Name
Family Doctor Address
Family Doctor Phone
Please enter a valid phone number.
What medications are you (child) currently taking? (name of medication, dosage, date started and side effects) If none please enter none.*
What supplements are you (child) currently taking? (name of supplement, how much and how often) - if none please enter none*
Are you (child) currently under the care of a Physician(s)? (Name of Physician, Condition and Treatment(s) )

Health History
Current Medical Complaints ~ main reasons for our appointment today. List in order of importance including possible cause and when it started.*
What major injuries or surgeries have you (child) had, if any? (type, location and what age did it occur) - if none please enter none*

Pregnancy History

Biological Parent and Child History
Parent's age at child's birth*
Parent's health during pregnancy? List any bleeding, nausea, illness, physical or emotional trauma, hypertension, diabetes, medications, alcohol, drug, cigarette consumption etc.*
Any significant cravings during pregnancy?
Birth History*

Full termPermatureLate
Weight at Birth
Length of labour and any interventions required*
Any complications or extended hospital stay, please elaborate

Age your child began:
Sitting
Enter age
Crawling
Enter age
Walking
Enter age
First Words
Enter age
Eating solid foods
Enter age
Feeding*

Breast feedFormulaBoth
Favorite Foods*
Food Intolerances/Allergies*
What vaccinations have you (Child) had and any adverse reactions? If none, please type none*

Consent

Note: If under 18 years of age, a parent or guardian must sign on your (Child) behalf. Thank you for taking the time to complete this form. All information contained herein will remain strictly confidential.
I, Enter parent name the undersigned, understand that Sandra O'Grady HOM, R.BIE is a Registered Homeopath and Bioenergetic (BIE) practitioner and not a licensed medical doctor.
(Please check each of the following after reading)*

As such, I acknowledge that I am here on my own behalf and it is my right and responsibility, at any time throughout my care with Sandra O’Grady, to seek medical counsel and diagnosis, if so desired from a licensed medical doctor, for any present and/or future condition(s).I acknowledge that Sandra O’Grady does not diagnose or give direction on any current medications or diagnosis treatment plan from my licensed medical doctor.I reserve the right to terminate homeopathic and BIE treatment at any time if so inclined. I acknowledge that the state of my health is my own responsibility and that I am exercising my right to choose an alternative method of treatment, in homeopathy or BIE, that addresses my health in its entirety.I consent that after assessment, answering of questions, and discussion of homeopathic treatment options, to my satisfaction, I will voluntarily follow recommended treatment advice. I understand I can withdraw my consent at any time.I acknowledge that I understand the risks, limitations, conditions of use, and instructions for use of the select electronic communication Services such as email, text, videoconferencing (Skype, Zoom, FaceTime) and phone.I acknowledge and understand that despite recommendations that encryption software can be used as a security mechanism for electronic communications, it is possible that communications with Sandra O’Grady may not be encrypted. Despite this, I agree to communicate with the Homeopath understanding of the risk.In regards to BIE solely, I acknowledge that the GSR-120 unit is not intended to be used to diagnose, cure, prognosticate, treatment or prescribing of remedies for the treatment of disease or any act which will constitute the practice of medicine in this country in which a medical license is required.The GSR-120 unit is used to direct energy directly onto various acupuncture points on the body to help create homeostasis.Homeopathy is not covered by existing government medical insurance plans; therefore, I agree to pay all fees incurred as presented in the current rate schedule.
Please sign below advising of your consent on behalf of your underage child*

Clear
Date

MonthDay Year
Please note:

All information submitted will be kept strictly confidential. Information is stored on secure servers and will not be disclosed to any 3rd party.
Should be Empty:

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CHILD New Patient Intake Form

Health Information

Health History

Pregnancy History

Age your child began:

Symptoms experienced in past 6-12 months:

Conditions that you (Parents/Grandparents) have had in your lifetime:

Allergies or intolerances:

Environmental Survey

Consent

Please note: