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  • LONGEVITY HEALTH CENTER Child Comprehensive Intake Form

  • 1. PATIENT INFORMATION

  • Date:
     - -
  • DOB:
     - -
  • Gender:
  • Format: (000) 000-0000.
  • Are both parents supportive of alternative care:
  • Format: (000) 000-0000.
  • Would you like to receive our newsletter?

  • 2. PRIMARY HEALTH CONCERNS

  • Rows
  • 0/40
  • 0/40
  • 0/40

  • 3. CURRENT MEDICATION AND SUPPLEMENTS

  • Rows
  • Rows

  • 4. CURRENT SYMPTOM SEVERITY (0 = none, 5 = worst)

  • Rows

  • 5. MEDICAL HISTORY

  • Vaccinations (check all received):
  • Did the child have any reactions/side effects following shots:
  • Reactions/Side Effects:

  • BIRTH STORY:

  • Mom's exposure to:
  • Did mom receive any vaccinations while pregnant? Check all that apply
  • Was baby born:
  • Was the child born full-term?
  • Were there any interventions during/at birth?
  • Was breastfeeding established?
  • 0/40
  • 0/40
  • Frequency of ear infections, strep, viruses:
  • Fevers usually run
  • Response to illness:
  • Are there any siblings?

  • 6. DEVELOPMENTAL MILESTONES

  • Rows
  • Rows

  • SOCIAL & EMOTIONAL DEVELOPMENT

  • Does the child become easily overwhelmed (noise, crowds, transitions)?
  • How quickly do they calm down after distress?
  • Are there frequent meltdowns or shutdowns?
  • Self-soothing behaviors
  • Does the child make consistent eye contact?
  • Do they show or share things of interest?

  • COMMUNICATION DEVELOPMENT

  • Are there delays in speech or language?

  • PLAY & IMMAGINATION

  • Does the child engage in pretend or imaginative play?
  • Do they imitate others' actions?

  • BEHAVIOR PATTERNS AND ROUTINES

  • SENSORY PROCESSING

  • NUTRITION & GUT HEALTH

  • Appetite pattern:
  • Processed food intake:

  • SLEEP PATTERNS

  • Is there a structured bedtime routine:
  • Does the child fall asleep easily
  • Do they wake frequently at night
  • Mouth breathing or snoring
  • Sleeping arrangement:

  • ENERGY, FOCUS & ATTENTION

  • Can the child sustain attention on tasks?
  • Are they hyperactive, impulsive, or unusually low energy
  • Do they hyper-focus on specific interests?

  • 7. School Experience

  • Select all that apply to your child:

  • 8. ALLERGIES / SENSITIVITIES

  • Does the child react to specific foods immediately?

  • 9. NUTRITION INTAKE:

  • Does the child follow a special diet?
  • Rows
  • Rows

  • 10. TOXIN EXPOSURES

  • Check all that apply:
  • Water filtration system in the home:
  • Air filters in the home:
  • Has the child lived outside the U.S.?

  • 11. Dental History

  • Amalgam Fillings?

  • 12. FAMILY MEDICAL HISTORY

  • Family diagnosis (mother/father side):

  • 13. YOUNG WOMEN ONLY (if applicable)

  • PMS Painful Periods Heavy Bleeding Irregular Cycles
  • Endometriosis Fibroids PCOS
  • Last PAP:
  • Check all that apply:

  • 14. YOUNG MEN ONLY (if applicable)

  • Urinary frequency at night?
  • Erectile concerns?

  • 15. HEALTH GOALS & READINESS

    Top 3 things you would like to change about your child's health:
  • Please rate family readiness for lifestyle change:

  • 16. YOUR CHILD'S STORY

  • Authorization to Release Health Information

  • I authorize Longevity Health Center to disclose my protected past, present and future health information to the following people or entities:
  • This health information may be used by the person I authorize for health treatment or billing/payment purposes. This authorization will remain in effect until such time as I choose to revoke the authority in writing.
  • Date
     - -

  • STATEMENT OF UNDERSTANDING

  • I acknowledge that the modalities utilized by Alice Honican, DTCM, ND, L.Ac., Cristina McMullen ND, Maria Jones, ND, and Janelle Bertler, ND, at Longevity Health Center are not approved for medical evaluation or diagnosis. The bio-energetic assessments performed may indicate "disturbance signals" related to microbial or environmental pollutants, but these are not to be interpreted as a medical diagnosis. The information gathered is intended solely to guide the development of a recommended protocol for holistic wellness. I also understand that none of the practitioners or staff members at Longevity Health Center are medical doctors. I voluntarily choose to undergo an evaluation and treatment based on oriental medical principles, including traditional and modern acupuncture techniques.

  • CANCELLATION POLICY – $50 Missed Appointment Fee

  • We strive to provide timely and quality care to all our patients. To ensure the availability of appointments, please be aware of the following policy:
    • Late Cancellations: Appointments must be canceled at least 24 hours in advance. If you cancel with less than 24 hours' notice, it will be considered a late cancellation.
    • No-Shows: A no-show occurs when a patient misses an appointment without prior notice.
    In either case, a $50 missed appointment fee will be charged. When you book an appointment, you reserve a time slot that could have been offered to another patient. Timely cancellations allow us to accommodate other patients in need of care.
  • If you need to cancel your appointment, please call us at 770-642-4646 between 9:00 AM and 5:00 PM. If you call outside of business hours, please leave a detailed voicemail. We will return your call as soon as possible.
  • I have read and understand the above CANCELATION POLICY.
  • I have read and understand this STATEMENT OF UNDERSTANDING.
  • Date
     - -
  •  
  • Should be Empty: