Pediatric Patient Intake Survey
Please complete this form to help us provide the best care for your child. All information is confidential and used solely for medical assessment.
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Gender
*
Male
Female
Other
Parent or Guardian Name
*
First Name
Last Name
Parent or Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent or Guardian Email
*
example@example.com
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Does the child have any known allergies?
No known allergies
Food allergies
Medication allergies
Environmental allergies
Other (please specify)
Current Medications (please list all that the child is currently taking)
Has your child received all recommended vaccinations for their age?
Yes, up to date
No, delayed schedule
Not sure
Never vaccinated
Yes and I wish to continue vaccines as recommended
I wish to no longer receive vaccines
Type of concern:
Medical
Behavioral
Both
Have you tried anything to help symptoms? (Therapy, home changes, supplements)
Medical History
Rows
Yes
No
Asthma
Diabetes
Heart condition
Seizures
Surgeries
Hospitalization in the past year
Other chronic conditions
Autism
Menal Health Diagnosis
Please check all conditions that your child is currently experiencing or has experienced in the past
Rows
yes
Strep Throat
Chicken Pox
Ear Infections
Sinus Infections
Pneumonia
Constipation
Mono
Chronic Runny Nose
Hives/Rashes/Eczema
Colic/gas/cramping
Cold Sores
Frequent colds
Frequent Tantrums
Tics/Habits
Current Height
Current Weight
Briefly describe any prenatal concerns or complications. (N/A for a normal uncomplicated birth)
Did your child meet milestones on time?
Yes
NO
If no, please explain
Briefly describe the reason for today's visit or any current symptoms:
*
Three-Day Food Diary
Rows
DAY 1
DAY 2
DAY 3
Breakfast
Snack
Lunch
Snack
Dinner
Other
Please rate the severity of your child's current symptoms:
1
2
3
4
5
What are your goals for your child health in the next 3-6 months?
Signature
Submit Intake Survey
Submit Intake Survey
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