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1 Today s date: Patient s Name Date of Birth / / Age Gender Sex assigned at birth Parent s name Parent s name Please indicate the type of care that you are seeking for your child: o Primary management of my child s health o Adjunctive care for my child s health o Ongoing management of my child s health o One time advice for my child s health o I don t know at this time. Last Physician Seen/ For what condition? Have you ever consulted a Naturopathic Doctor, IBCLC, or Acupuncturist before? Does your child have any medication, environmental, or food allergies? [ ] yes [ ] no If yes, please explain to what and what kind of reaction you had: Allergy (e.g., bees) Reaction (e.g. anaphylaxis, rash, etc) Please list all medications and supplements your child is taking including prescriptions, over the counter medications, vitamins, minerals, herbs, homeopathic remedies, and probiotics. Attach another page if needed. Name of Medication (such as culturelle, Vitamin C, etc ) Strength of medication (81 mg, etc) Directions (take twice a day away from food, etc)
2 Vitality Natural Medicine, PC From the Beginning Prenatal/Birth History: Is your child adopted? Was your child born pre-term? How many weeks gestation? Were there pregnancy complications? Type of birth Were there any birth complications? (i.e. shoulder dystocia, low APGAR, forceps, etc) Did you have an epidural? IV fluids? Is/was your child breastfed? yes no mixed feed donor milk Amount of time: Breastfeeding history: (if not applicable, leave blank) Does/is baby... o click while nursing o frequently break latch o have nursing blisters o favor one side over the other o have reflux o drool excessively o have difficulty latching o favor a nursing shield o colicky How many feeds per day? How long is each nursing session? How many wet diapers per day? How many bowel movements per day? Does/ is mama... o experience discomfort while nursing o have plugged ducts o have or has had thrush o have nipple trauma o sleep deprivation due to continual nursing o have mood swings with let down o have painful let down o have or has had mastitis How much water is mama getting? How much food is mama getting?
3 Does mama have support? Important for coordinating your care right now Medical history: (Check conditions and illnesses for which you have been treated and include year of onset. List any other conditions which may not be included below.) o No known medical problems o asthma o sensory issues o frequent colds o developmental delays o allergies o nerve palsy o constipation Past Surgical History: (indicate year) Appendectomy tonsillectomy hernia repair Other o diabetes o diarrhea o ADHD/ ADD o reflux o torticollis o bleeding disorder o genetic diagnosis o Other Conditions? Family History Please indicate who in your family has had these health problems and the age at diagnosis if known o Diabetes o Heart disease o High blood pressure o Cancer (specify type) o Auto immune diseases o Addiction problems o Psychiatric diagnosis o Bleeding problems o Genetic problems
4 Vitality Natural Medicine, PC Social History: o Do you feel safe in your home? o Do you have access to enough food to eat? o Is your child in daycare or school? o What grade is your child in? o Child s extracurricular activities: Does anyone in the house smoke? never past, pack(s) per day for years yes, pack(s) per day for years Exercise: none days per week type Average/ Typical daily diet: Breakfast Lunch Dinner Snacks Dessert Drinks Water Childhood illnesses has your child had: [ ] Scarlet fever [ ] Chicken pox [ ] Measles [ ] Mumps [ ] Rubella [ ] RSV [ ] Pertussis [ ] other, please specify:
5 Vaccinations: DtaP, Hib, PCV, IPV, MMR, Hep B, Hep A, Varicella, Pneumovax, and Influenza are typical American vaccines. Please also note vaccines given that are more common to other countries, such as tuberculosis. Vaccine Date given reaction, if any
Patient Intake Form - Child. Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling out this form? (name, relationhip):
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Patient Name DOB Age Sex: Male Female. Address City State Zip. Parent or Guardian Contact Information. Relationship to Child
Eric Udell, ND 1250 E Baseline Rd., Suite 104 Laurinda Kwan, ND Pediatric Intake Form Today s Date / / Patient Name DOB Age Sex: Male Female Address City State Zip Parent or Guardian Contact Information
Patient Information. How did you hear about the BIHC: If you were referred, please state by whom: If yes, by whom: Date of last visit: DD/MM/YYYY
Dr. Kelly Gillis, ND Doctor of Naturopathic Medicine Patient Information Date of initial appointment: DD/MM/YYYY Name: Address: Age: Date of Birth: DD/MM/YYYY Sex: M F Gender (if different than sex): Occupation:
CHILD INTAKE (Please Print Clearly)
Jeremy Hayman, ND CHILD INTAKE (Please Print Clearly) Doctor of Naturopathic Medicine Child s name (First/Last) Date of birth (M/D/Y) Sex M F Referred by Who is filling out this form (name and relation)?
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