Pediatric Intake Form
Child's Name:
Birth date:
-
Month
-
Day
Year
Date
Age:
1st Parent's Name:
Age:
Occupation:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail address:
example@example.com
2nd Parent's Name:
Age:
Occupation:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail address:
example@example.com
Parent's Marital Status:
Married/Partnered
Separated
Divorced
Widowed
Other
Siblings Names and Ages:
School and Grade:
Current Physician:
Please remember this is a confidential report. Your honest evaluation is both pertinent and necessary to better enable the practitioner to accurately assess the health of your child and effectively work with you to improve your child's general well-being.
I: Current Information:
Main health problem (when did it start, describe the course of symptoms, what treatment have you tried):
Is your child currently taking any medication or medicated topical?
Yes
No
If so, what medicine/medicated topical and for what condition
Is there anything that you would like to discuss without your child present? Describe:
II: Pregnancy:
Please check any area that applied to the child's mother before/during her pregnancy:
Child adopted
Regular prenatal care
HIV/AIDS
Fertility treatments/IVF
Attitude-Happy (majority of time)
Allergic reactions
Recreational drug use
Attitude-Depressed
Nausea/vomiting
Smoking
Complications in pregnancy
Physical injury
Alcohol
Any diagnosed illnesses
Mental trauma
Caffeine: cola,coffee,teas,chocolate,etc
Hospitalization
Toxic exposure
Medications
Forced bed-rest
Premature contractions
Daily vitamins/minerals
Excessive decrease in weight
Bleeding
Immunization during pregnancy
Excessive increase in weight
Carried to full term
Mother's age at child's conception:
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III: Labor and Delivery:
Home birth
Greater than 12 hours
Medications
Hospital birth
Complications
Forceps
Birthing center
Fetal monitor used
Cesarean
Premature delivery
Other
IV: Newborn History:
Pregnancy Duration (weeks)
Birth length
Birth weight
Please check any of the following areas your child had problems with at or after birth:
Breathing
Coloring
Crying
Nursing
Sleeping
Jaundice
Choking
Failure to thrive
Other
No
Rows
Yes/No
For how long?
Type of formula
Breast Fed
Yes
No
Bottle Fed
Yes
No
Patient is currently being fully or partially breastfed:
Yes
No
History of Colic
Yes
No
Normal Weight Gain
Yes
No
At what age were solid food introduced?
What foods initially?
V: Immunizations:
Please check all immunizations your child has received, at what age, and any reactions, if any:
Rows
Received
Age
Reaction
Diphtheria
Pertussis
Tetanus
Polio
HIB
Measles
Mumps
Rubella
Chickenpox
Hep B
Flu
Pneumococcus
VI: Hospitalizations and Illnesses:
Has your child ever been hospitalized or operated on?
Yes
No
Explain:
Has child ever had a serious accident (broken bones, head injuries, falls, burns, poisoning)?
Yes
No
Explain:
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Has your child ever had any of the following illnesses:
Asthma
Hay fever
Bronchitis
Pneumonia
Whooping cough
TB
Polio
Diphtheria
Measles
Mumps
Chickenpox
Rheumatic fever
Heart/blood vessel disease
Bleeding tendencies
Liver disease
Sickle cell disease
Epilepsy/Seizures
Diabetes
Other
Does your child have any allergy problems (rash, itching, swelling, difficulty breathing, sneezing, etc)
a) When eating food?
Yes
No
What foods?
How does the child react?
b) When taking medication?
Yes
No
What medicine?
How does the child react?
c) When near animals, furs, insects, dust, etc?
Yes
No
What things?
How does the child react?
d) At certain times of year?
Yes
No
When?
How does the child react?
VII General:
General Symptoms (Please check all that apply)
Poor appetite
Excess appetite
Change in appetite
Food cravings
Nail biting
Cold hands
Cold feet
Chills
Fever
Sweats easily
Insomnia/sleep problems
Heavy sleeper
Wakes in a foul mood
Irregular naps
Night sweats
Weakness
Poor coordination
Vertigo/dizziness
Fatigue
Snores while sleeping
Sudden energy drops-at what time?
Bleed or bruise easily-where?
What time does child usually go to sleep at night?
What time does child usually wake?
Does child nap?
Yes
No
When?
VIII Skin and Hair:
(Please check all that apply)
Rashes
Eczema
Change in hair/skin texture
Ulcerations
Pimples/Acne
Psoriasis
Hives
Itching
Moles/warts
Other
Complexion:
Pallor
Sallow
Fair
Dark
Ruddy
IX Head, Eyes, Ears, Nose, and Mouth: (Please check all that apply)
Head, Eyes, Ears, Nose, and Mouth Problems
Dizziness
Concussions
Facial pain
Eye strain
Color blindness
Night blindness
Eye pain
Spots in eyes
Poor vision
Blurry vision
Dark circles under eyes
Corrective lenses
Earaches
Ear infections
Ringing in ears
Poor hearing
Nose bleeds
Snotty/Runny nose
Nasal congestion
Sinus problems
Teeth problems
Grinding teeth
Cavities/fillings
Braces/orthodonture
Canker sores
Sores on lips or tongue
Recurrent sore throats
Ear tubes
Headaches - where and when?
Other head or neck problems?
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X Respiratory: (Please check all that apply)
Respiratory Symptoms
Cough
Coughing blood
Tight chest
Wheezing/Asthma
Difficulty in breathing when lying down
Frequent or recurrent colds/flu
Production of phlegm
Other
Production of phlegm - color?
XI Gastrointestinal: (Please check all that apply)
Gastrointestinal Symptoms
Nausea
Sensitive abdomen
Bloody stools
Rectal pain
Vomiting
Pain or cramps
Black stools
Hemorrhoids
Belching
Excess Gas
Constipation
Anal itching
Bad breath
Diarrhea
Other
Laxative Use per week:
Type:
Bowel Movements: Frequency:
Color:
Odor:
Texture/Form
XII Genito-Urinary:
(Please check all that apply)
Pain on urination
Frequent urination
Blood in urine
Urgency to urinate
Unable to hold urine
Bedwetting
Wakes to urinate-How often /night
Urinary tract infections
Vaginal infections
Discharge from vagina or penis
Early sexual development
Other
XIII. Musculoskeletal: (Please check all that apply)
Musculoskeletal Symptoms
Neck pain
Back pain - Where?
Muscle cramps
Joint pains - Where?
Sprains/Strains
"Growing" pains
Shin splints
Excessively ticklish
Other
XIV. Neuro-psychological: (Please check all that apply)
Neuro-psychological Symptoms
Fidgety (hands and feet)
Impatient
Difficulty completing tasks
Easily stressed/anxious
Seizures
Trouble with reading/Concentrating
Bad temper
Social difficulties
Learning disabilities
Hyperactive
Nightmares/terrors
Sleepwalks
Other
Predominant emotion/mood:
Angry
Sad
Worried
Happy
Shy
Fearful
Depressed
Treated for emotional problems - describe:
Please describe any emotional stresses, shocks, or traumas your child may have experienced:
Please describe your child's living situation:
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XV: Family Medical History: If any blood relative to your child has or have had any of the following illnesses, please check accordingly: M (Mother), F (Father), S (Sibling), PGM (Paternal Grandmother), PGF (Paternal Grandfather), MGM (Maternal Grandmother), MGF (Maternal Grandfather)
Rows
M
F
S
PGM
PGF
MGM
MGF
Allergy, asthma, or eczema
Auto-immune disease
Cancer
Diabetes or low blood sugar
Heart trouble
High blood pressure/Stroke
Kidney disease
Liver disease
Tuberculosis
Thyroid problems
Neurological conditions
Mental illness/Nervous disorder
Alcoholism/Addiction
Other:
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XVI. Diet/Nutrition:
What are your child's three favorite foods?
What are the three healthiest foods your child eats during an average week?
What are the three worst foods that your child eats during an average week?
Dietary habits (Please check all that apply): D=Daily F=Frequently O=Occasionally R=Rarely N=Never
Rows
D
F
O
R
N
Fresh Fruits
Fresh Vegetables
Raw Foods
Sprouted Foods
Whole Grains
Unrefined cereals
Legumes/Beans
Nuts/Seeds
Dairy Products
Peanut Butter
Honey/Molasses
Fruit Juices
Soy Products
Eggs
Fish
Fowl
Red meat
Hot dogs/Cold cuts
White Flour Products (Bread, bagels, crackers, pasta)
White Sugar Products
Artificial Sweeteners
Artificial Colors
Fried Foods
Fast Food
Pre-Packaged Foods
Soda Pop
Chocolate
Candy/Sweets/Desserts
List herb, vitamin & mineral supplements your child is currently taking:
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Is there anything else that you would like to share about your child?
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