Existing patient form

Pediatric intake form

for any fields that do not apply to you, please leave blank unless otherwise indicated.
What services are you seeking?
Contact Information
Patient name

First NameMiddle NameLast Name
Preferred name:
Preferred pronouns:
Patient Birthday

MonthDayYear
Date
If the person completing this form IS NOT the patient listed above, please provide your name (first AND last) and relation to the patient.
Patient Social Security number:
Patient 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:
How do you prefer we communicate with you?
Who is the patient's insurance carrier? (ex: BCBS, Aetna, Soonercare). If you don’t have insurance, write self-pay.
File Upload

Please upload a picture of the FRONT SIDE of your insurance card.
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File Upload

Please upload a picture of the BACK SIDE of your insurance card.
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What pharmacy would you like us to send medication to? (Please provide name and address).
How were you referred to our clinic? (if you weren't referred, leave blank)
Tell us a bit about why you want to schedule an appointment:
Demographics
Please list your gender-identity (ex: male, female, non-binary, etc.)
Please list the people living in your home:
What is the patient's religious affiliation?
Are there any cultural/ethnic/spiritual or other considerations you would like us to know about?
What does the patient like to do in their free time?
Does the patient have any issues making or keeping friends? If applicable, does the patient have any issues getting along with siblings? (if no, write n/a).
What are the patient's strengths?
Please list any past or ongoing legal issues:
Highest grade completed:
Current grade:
Name of school presently attending:
Number of schools previously attended:
Has the patient dealt with any of the following school related issues?

504 Plan/IEPSkipped gradesHeld back a gradeExpulsionOccupational therapySpeech therapyPhysical therapySuspension (in school)Suspension (out of school)BullyingRequire special help
Medical History
Height:
Recent weight:
Date of last Physical Exam:
Are the patient's immunizations up to date?
Please provide the name and number of patient's Primary Care Provider (write n/a if you don’t currently have one).

Has the patient or someone in the patient's immediate family been diagnosed with any of the following:

Rows	Patient	Mom	Dad	Sibling	Child	Other
Anemia
Asthma
Cancer Leukemia
Cerebral Palsy
Diabetes
Down's Syndrome
Encephalitis
Epilepsy/seizures
Hearing Problems
Heart disease
HIV/AIDS
Hypertension
Loss of consciousness/head injury
Meningitis
Musculo-skeletal condition
Stroke
Thyroid Problems
Vision Problems
Dementia/Alzheimer's

Please list ANY OTHER serious and/or chronic illnesses patient has. If they have none, write n/a.
Please list any past surgeries with approximate dates:
Is the patient sexually active?
If yes, what contraception method do they use?
Is the patient currently, or have they recently experienced any of the following symptoms:

ChillsChronic painBlurred/double vision/vision changeWeight gainWeight lossFeverChest painChest tightnessLower extremity swellingSexual dysfunctionIncontinenceFaintingFrequent headachesSeizureEye painChronic coughShortness of breathJoint pain/swellingMuscle painHeartburnItchingSinus pressure/congestion/drainageSore throatSkin lesions/rash/hivesFrequent constipationFrequent diarrheaNauseaVomitingCold or heat intoleranceFrequent urination
Any medication, food, or environmental allergies? What type of allergic reaction do you have? (write NKDA if none):
Please list all current NON-PSYCHIATRIC prescription medications, as well as any supplements, vitamins, or over-the-counter medications you take on a regular basis. Please include the strength and directions (ex: Lisinopril 10 mg every morning, Olly Sleep Gummy every night as needed for sleep.) If they are not on any medication, write n/a.
Behavioral Health History
Please list any CURRENT psychiatric medications, including medication strength and instructions (ex: Prozac 20 mg every morning). If they are not on any medication, write n/a.
Please list any PAST psychiatric medications including medication strength and response (ex: "worked well", "made anxiety worse", "caused a rash"). If they have not been on any medications in the past, write n/a.
Please list any PAST behavioral health care (inpatient, outpatient, psychological testing) along with approximate dates and provider names. If they have not had any past care, write n/a.
List any past suicide attempts or history of self-harm with dates.
If patient is currently seeing therapy, please provider their name and office name.

Has the patient or someone in their family been diagnosed with any of the following:

Rows	Patient	Mom	Dad	Sibling	Other
ADD/ADHD
Anxiety
Bipolar Disorder
Depression
DMDD
Eating Disorder
Encopresis/Enuresis
Hallucinations/Delusions/Paranoia
Learning/developmental disorder
OCD
ODD
Panic Attacks
Personality Disorder
PTSD
Schizophrenia
Substance Abuse/Dependency
Reactive Attachment Disorder
Night terrors
Nightmare Disorder

Does the patient have any of the following sensory issues?

Overly sensitive to soundsLight sensitivityTexture issuesCoordination issues
Age of mother at time of birth?
Age of father at time of birth?
Did your mother use any of the following during pregnancy?

AlcoholCigarettesMarijuanaCocaine/crackOpiates/Heroinother illicit substances
Where there any complications during the birth or did patient require any time in the NICU following birth?
How often does the patient exercise?
How would you describe the patient's diet/eating habits?
Examples of typical diet:
Does the patient have any issues with completing chores or other at home responsibilities? Do they need prompting to complete said responsibilities?
Does the patient perform age appropriate self-care? Do they need prompting to complete said self-care?
Has the patient engaged in any past or current substance use (including nicotine and cannabis)? If so, please provide approximate dates and any other information you feel is important.
Should be Empty:

Pediatric intake form

Contact Information

Demographics

Medical History

Behavioral Health History