Pediatric Intake Questionnaire

PEDIATRIC INTAKE QUESTIONNAIRE

For any inquiries, please call (503) 922-1999 (Oregon) or (757) 239-2293 (Virginia Beach or email us at alisfamilypsychteam@hushmail.com

Please fill out this form as completely as possible. This information will help us to better assess your child before any consultation.
Alis Family Psychiatry
Todays date

MonthDayYear
Person completing form
Relationship to patient
PATIENT INFORMATION
Name

First nameLast Name
Preferred Pronouns (Optional)
e.g., she/her, they/them, he/him
Gender at Birth
Date of birth

MonthDayYear
Date
Permanent address
City
State
Country
Zip code
Home phone
Format: (000) 000-0000.
Cell phone
Format: (000) 000-0000.
Work phone
Format: (000) 000-0000.
Email
example@example.com
Preferred Pharmacy
Include which retail/mail pharmacy chain and address/zipcode of pharmacy location
PARENT(S) INFORMATION
Mother's Name

Mothers first nameMothers last name
Father's Name

Father’s first nameFather’s last name
Other Guardian's Name

Other guardian first nameOther guardian last name
Who is the patient’s primary caretaker?

Other (Please specify)
Note: If parents are separated or divorced, or if someone other than the biological parent is the primary caretaker, custody or power of attorney paperwork must be on file prior to receiving care.
REFERRING PHYSICIAN INFORMATION
Name

First nameLast name
Specialty
Office address
Office phone no.
Format: (000) 000-0000.
Office fax no.
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
INSURANCE INFORMATION
Name of Insurance Provider
Subscribers name
Subscriber's DOB:

MonthDayYear
MM-DD-YYYY format
Policy number
Group number
Patient’s Social Security Number
Insurance Guarantor’s Social Security Number

Rows	Diagnosis
1.
2.
3.

PATIENT INFORMATION

PARENT(S) INFORMATION

REFERRING PHYSICIAN INFORMATION

INSURANCE INFORMATION

SUMMARY OF PRESENT ILLNESS/PRIMARY CONCERN

Pregnancy History (Complications)

Pregnancy History (Medications or Drugs)

Pregnancy History: Tests & Procedures

Delivery

Birth History

Developmental history