Pediatric Intake Form

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.
Demographics
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.
Email*
example@example.com
Genetic background
Medical Information
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.
Fax Number
Please enter a valid phone number.
Specialists
Medical History
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.

AutismAllergies (seasonal)AsthmaEar infectionsStrep throatMonoEczemaIrritable bowel syndromeAnal fissuresEsophageal reflux / gastritisCOVID-19InfluenzaAnemiaIron deficiencyVitamin-D deficiencyHeart murmurHeart arrhythmiaPericarditisPneumoniaBronchitisSinusitisAcneDiabetesHigh blood pressureArthritisBroken bonesAnxietyDepressionMood disorderADD/ADHD
Has the child received frequent antibiotics( more than once per year)?

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

YesNo
Diet & Nutrition
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.

Breakfast cerealsOatmealPop tartsPastaMacaroni and cheeseYogurtMilkCheeseCookiesCrackersDonutsCakePastriesBreadRiceCornCandy barsHard candyChicken fingersOnion ringsFrench friesPotato chipsTortilla chips
Does your child eat red meat?

YesNo
Does your child eat chicken?

YesNo
Does your child eat pork?

YesNo
Does your child eat dairy (cheese)?

YesNo
Does your child eaten fish or shellfish?

YesNo
Does your child eat vegetables?

YesNo
Does your child eat fruits?

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

YesNo
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?

YesNo
Has your child ever been diagnosed with lactose intolerance?

YesNo
Does the child drink soda?

YesNo
Does the child drink coffee?

YesNo
Does the child drinks tea?

YesNo
Does the child drink fruit juices?

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

YesNo
Psycho-Social
Does the child seemed generally happy?

YesNo
Is there any history of abuse?

YesNo
Parental Environment ( please check any that apply )

Biological mother and fatherSingle parentFoster parentsDivorced or separated parentsAdopted
Does the child have any siblings?

YesNo
How is the relationship with the siblings?
Were there any developmental delays?

YesNo
If yes, please describe these here.
Does the child have friends?

YesNo
How are they in social situations?
Is the child in school?

YesNo
If yes, how are they performing in school?
Have they ever been evaluated by a psychiatrist or therapist?

YesNo
Fitness & Activities
Is the child physically active?

YesNo
Does the child have any physical limitations?
Does the child participate in sports?

YesNo
If yes, which sports?
Has a child sustained any injuries?

YesNo
If yes, please list them here.
Toxins
Has the child been exposed to any of the following when? Please check all that apply.

MoldElectromagnetic frequency radiationPower linesOld paintPesticidesHerbicidesHarsh ChemicalsCleaning agents
Dental: please check all that apply.

Amalgam fillingsRoot canalCaps/crownsGingivitisBleeding comes
Does the child receive acetaminophen regularly ( more than once per month)?

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

YesNo
Has the child ever been jaundiced?

YesNo
Signature of legal guardian*

Clear
Date signed*

MonthDayYear
Date
Should be Empty:

Pediatric Intake Form

Demographics

Medical Information

Medical History

Diet & Nutrition

Psycho-Social

Fitness & Activities

Toxins