Pediatric Intake Form

Please complete each section as thoroughly as possible. The more information and details provided, the better we will be able to proceed with a plan moving forward.

If there have been any labs or other studies performed, please upload those on to the patient portal, or requests that they be forwarded to us by fax to (828) 222-4510.

Child's Name

First NameLast Name

Father's Name

Mother's Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Genetic background

Primary Care provider:

Office/Practice Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number

Please enter a valid phone number.Format: (000) 000-0000.

Specialists

Current Symptoms/Condition

What has been done so far to evaluate these concerns?

What has been attempted to address these concerns?

What do you think may be contributing to the symptoms or condition?

Does anything seemed to make symptoms worse?

Does anything seem to make the symptoms better?

What health goals do you hope to achieve from this appointment?

Medication Allergies

Non-Medication Allergies

Current Medications

Previous Medications

Medical Conditions

Surgeries

Diagnostic Procedures Performed

Lab Testing Performed

Family History (parents, grandparents, aunts, uncles, siblings)

Has the child ever been diagnosed with any of the following conditions? Check all that applied.

Has the child received frequent antibiotics( more than once per year)?

Has the child never been treated with corticosteroids ( e.g., prednisone)?

What does your child typically eat for breakfast?

What does your child typically eat for lunch?

What does your child typically eat for dinner?

What does your child typically eat for snacks?

What does your child typically drink throughout the day?

Please check any of the following that your child eats on a regular basis.

Does your child eat red meat?

Does your child eat chicken?

Does your child eat pork?

Does your child eat dairy (cheese)?

Does your child eaten fish or shellfish?

Does your child eat vegetables?

Does your child eat fruits?

Does your child eat nuts/seeds (including nut butters)?

What are your child's favorite meals?

What type of vegetables does your child eat?

What type of fruits does your child eat?

Has your child ever been diagnosed with food allergies?

Has your child ever been diagnosed with lactose intolerance?

Does the child drink soda?

Does the child drink coffee?

Does the child drinks tea?

Does the child drink fruit juices?

Has the child been treated with acid blocking medications ( i.e., Prilosec, Prevacid, Nexium )?

Does the child seemed generally happy?

Is there any history of abuse?

Parental Environment ( please check any that apply )

Does the child have any siblings?

How is the relationship with the siblings?

Were there any developmental delays?

If yes, please describe these here.

Does the child have friends?

How are they in social situations?

Is the child in school?

If yes, how are they performing in school?

Have they ever been evaluated by a psychiatrist or therapist?

Is the child physically active?

Does the child have any physical limitations?

Does the child participate in sports?

If yes, which sports?

Has a child sustained any injuries?

If yes, please list them here.

Has the child been exposed to any of the following when? Please check all that apply.

Dental: please check all that apply.

Does the child receive acetaminophen regularly ( more than once per month)?

Does the child routinely receive NSAIDs ( i.e., ibuprofen )?

Has the child ever been jaundiced?

Signature of legal guardian

Date signed

Date

Pediatric Intake Form

Demographics

Medical Information

Medical History

Diet & Nutrition

Psycho-Social

Fitness & Activities

Toxins