Patient Intake Form
Child's Information
Name
First Name
Middle Name
Last Name
Preferred Name
Primary Address
Mailing Address
Street Address
City
Province
Postal Code
Birthdate
-
Month
-
Day
Year
Date
Biological Sex
Female
Male
Personal Health Number
Pharmacy
Family Physician/Nurse Practitioner
Clinic Name and Address
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Information about Biological Mother
Name
First Name
Last Name
Address (if different from child)
Mailing Address
Street Address
City
Province
Postal Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of birth
-
Month
-
Day
Year
Date
Occupation
Please list any health/mental/emotional/behavioural concerns
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Information about Biological Father
Name
First Name
Last Name
Address (if different from child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of birth
-
Month
-
Day
Year
Date
Occupation
Please list any health/mental/emotional/behavioural concerns
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Information about Siblings
Please list all siblings including step siblings
Siblings: Name, birthdate, full/half/step/ any health concerns
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Home/Family Arrangements
List all members living in the home
Do any members living in the home smoke or vape?
No
Yes, outside the home
Yes, inside and outside the home
Are there any pets in the home?
Yes
No
Do both parents share custody
Yes
No
Primary Caregiver/Guardianship (if different from parent). Please provide name, phone number and relationship.
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Duration of pregnancy (weeks)
Weight at birth
Childbirth and Delivery Method
Vaginal Delivery
Caesarean Section
Vacuum Extraction
Forceps
During the pregnancy, did Mother of the child smoke cigarettes:
No
Less than 1/2 pack per day
1/2 to 1 pack per day
More than 1 pack per day
During pregnancy, did Mother of the child drink alcohol?
No
First three months only
Throughout most of the pregnancy
Amount each time (1 drink =1 beer, 1 glass of wine, or 1 mixed drink):
1-2 drinks
3-5 drinks
6 or more drinks
Not applicable
Frequency of alcohol consumption:
Once per week
Two or more times per week
Not applicable
Please list any prescription or non-prescription medications taken during pregnancy:
Please list any narcotics (marijuana, cocaine, heroin, etc.) taken during pregnancy:
Please list any ultrasound abnormalities:
Please list any complications during the pregnancy:
Did the baby have any problems after the delivery that needed medical attention (ex: difficulty breathing, seizures, paralysis)? Describe:
Infancy and Early Childhood
Feeding:
Breastfed
Bottle-fed
Both
Did Mother of the child suffer Post Partum Depression?
No
Yes
Is your child meeting their developmental milestones on target?
Yes
No
Medical History
Please list any previous or current medical concerns:
If your child has been admitted overnight to the hospital since being discharged after birth, please list date and reason for admission:
If your child has had a surgical procedure, please list date and surgical procedure performed:
Does your child have any drug allergies or non-drug allergies?
No
Yes
Are your child's immunizations up to date?
No
Yes
Unimmunized due to age
Please list any medication or supplements your child is currently taking:
Has your child's hearing been tested?
No
Yes
Additional Information
Does your family have difficulty making ends meet at the end of the month?
No
Yes
Unsure
Do you have extended health benefits for your child?
No
Yes
Unsure
Name of individual completing the form:
First Name
Last Name
Submit
Should be Empty: