Benna Lun BSc(Hons) ND Naturopathic Doctor
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- Elmer Montgomery
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1 Today s Date: WHO IS FILLING OUT THIS FORM? Name (Please print) Relationship to child PATIENT INFORMATION Name: First name Middle name Last name How would you like us to address the child? Date of Birth (MM/DD/YYYY): Current Age: Sex: Street address Apartment # City Postal code Province Please provide your contact information below and indicate whether or not we may leave messages relating to the child s appointments: Message? Message? (H) phone (W) Phone EMERGENCY CONTACT INFORMATION Name: Relationship: Phone numbers: H: ( ) OTHER: ( ) HOW DID YOU HEAR ABOUT OUR CLINIC? Website Walk-in/Clinic Patient Pamphlet/Flyer Cell Referred by another patient Referred by staff member Referred by health care provider Other (please specify: HEALTH CARE PROVIDERS Please list the other health care providers from whom the child currently receives treatment: Fax: ( ) Fax: ( ) Page 1 of 6
2 Health care providers (continued) Fax: ( ) Fax: ( ) Does the child have regular screening tests with another Doctor (e.g. yearly physicals, etc.)? Yes No CHIEF CONCERNS Please list the top health care concerns for which you are seeking treatment in order of importance to you: MEDICAL HISTORY How is the child s general state of health? Excellent Good Average Fair Poor Please list any past health concerns, including major illnesses, hospitalizations, surgeries, etc., with approximate dates: Does the child have any allergies (medication, seasonal, environmental, etc.)? Page 2 of 6
3 Please complete the following table regarding the child s medications and supplements: CURRENT medications Drug name Date started Dose What is this drug being taken for? PAST medications Drug name Date ended Dose What was this drug being taken for? CURRENT supplements (including vitamins, minerals, herbs, homeopathics, etc.) What is this supplement being Supplement name Date started Dose taken for? Does the child use any over-the-counter (non-prescription) medications? Please list: Page 3 of 6
4 Please indicate which immunizations the child has received: Common childhood vaccines (North America) DPT (Diptheria, pertussis, tetanus) MMR (Measles, Mumps, Rubella) Polio Smallpox Tetanus booster when? Hemophilus influenza B Hepatitis A Hepatitis B Flu shot Other: Did any of the vaccines cause a negative reaction? Please describe: FAMILY MEDICAL HISTORY Please indicate any health conditions occurring in the child s family. Include parents, siblings, grandparents, aunts, and uncles and specify maternal/paternal lineage. Health condition Family member(s) Heart disease (heart attack, stroke, etc.) High blood pressure Diabetes Asthma Eczema or other skin condition Thyroid disease Arthritis/Rheumatism/other muscle or joint condition Cancer Blood disorder Environmental/seasonal allergies Other (please describe): I don t know the child s family medical history Page 4 of 6
5 HEALTH & DEVELOPMENT Benna Lun BSc(Hons) ND How was the child s health in his/her childhood? Excellent Good Average Fair Poor Has the child entered puberty? No Yes - If Yes: Any health changes occurring with puberty of concern? Describe the child s sleeping pattern/ sleep difficulties: How would you describe the child s temperament? How would you describe the child s behaviour and performance at school? DIET What does the child usually eat on a typical day? Please indicate examples and quantities. Breakfast: Lunch: Supper: _ Snacks: _ Beverages: Are the child s meals typically prepared at home or purchased? Does the child have any food allergies, sensitivities, or intolerances (that you know of)? Does the child have any dietary restrictions (religious, vegetarian/vegan, etc.)? Page 5 of 6
6 ENVIRONMENTAL HISTORY Is the child is currently in: Home-school Other: School: Grade What is the child s activity level? Inactive Mildly active Moderately active Active What are the child s favourite activities? How much TV does the child watch? hours/week How much time does the child spend at a computer/playing video games? hours/week Is the child exposed to significant amounts of smoke (including tobacco smoke) or other forms of pollution through school, hobbies, home environment, etc.? Is the child frequently exposed to animals (including pets)? _ How is the child s home heated? How would you describe the emotional climate of the child s home? Is there anything you feel is important that has not been covered? Thank you for taking the time to complete this form Page 6 of 6
HILLCREST CENTRE FOR HEALTH 832 St. Clair Ave W. Toronto, ON M6C 1C1 Tel: Fax:
Adult Intake Name Date of first visit Date of birth (M/D/Y) Gender M F Address: E-mail Address: May we add you to our mailing list? (Your email address will not be shared): Y N Telephone number: Home:
Paediatric Intake (0-12) George Tardik B.Sc, ND- Naturopathic Doctor
Paediatric Intake (0-12) George Tardik B.Sc, ND- Naturopathic Doctor Name Date of birth Sex M F Date Address Phone h w other May we leave messages relating to your visits? Y N Which one? Emergency contact:
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)?
Adult Intake Form. Please complete this form before your first visit
Adult Intake Form Please complete this form before your first visit Name: Date: Date of Birth: (MM/DD/YYYY) Gender: Marital status: Address: Email address: Home telephone number: Work telephone: Emergency
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:
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):
Patient Intake Form - Child Dr. Daria Novy, ND 2-228 Second St. West Cornwall, ON K6J 1G7 T: 613 938-9500 F: 855 820-1240 Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling
CARY HOLISTIC HEALTH, LLC. Thank you for scheduling an appointment with Cary Holistic Health. Maggie Thibodeau, ND
Maggie Thibodeau, ND CARY HOLISTIC HEALTH, LLC 222 Ashville Avenue, Suite 10 / Cary, NC 27518 (919) 858-1004 / CaryHolisticHealth.com Thank you for scheduling an appointment with. We are located at 222
We look so forward to seeing you at your first visit! If you have any questions, don t hesitate to call us at (705)
Welcome to StoneTree, and to the first steps on your way to feeling better! Thank you for choosing us as a part of your health care team. Your Forms and Health History Your new patient intake forms are
ROB AYOUP NATUROPATHIC DOCTOR. Pediatric Medical Intake. Name Date. Phone Home May messages be Work left relating to your Other visits?
ROB AYOUP NATUROPATHIC DOCTOR Pediatric Medical Intake Name Date Date of Birth Sex M F Address Phone Home May messages be Work left relating to your Other visits? Y N Guardian Name Emergency Contact: Name
PEDIATRIC Patient Intake Form
PEDIATRIC Patient Intake Form Dr. Amy Henehan, BA, ND Naturopathic Doctor Newcastle Family Chiropractic 10 King Ave. East, Newcastle, ON L1B 1H6 Last Name First Name Middle Name Date Date of Birth M/D/Y
Dr. Michelle Mackay Patel, ND
NATUROPATHIC PEDIATRIC INTAKE FORM (Birth to 12 years) PERSONAL INFORMATION: Child s Given Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: Gender: MALE / FEMALE Current Height/Length: Current Weight:
CHILD INTAKE FORM. Name: Date: Date of birth (M/D/Y): Age: Gender:
1/4 CHILD INTAKE FORM Name: Date: Date of birth (M/D/Y): Age: Gender: Contacts (in order of preference) please * beside the name whom the child lives with Name: Relationship: Address: City, Prov: Postal
Child Intake Form. In case of emergency, contact: Relationship: Phone:
Personal Information Date: Child Intake Form Name of child: Sex: M F Age: Birth Date: Name of parent/guardian: Address: City: Province Postal code: Telephone (Home): (Work): (Cell): Email: Preferred contact
ARGYLE NATURAL HEALTH CENTRE NATUROPATHIC INTAKE FORM. Full Name: (First) (Middle) (Last)
ARGYLE NATURAL HEALTH CENTRE NATUROPATHIC INTAKE FORM Full Name: (First) (Middle) (Last) Date of Birth: / / Age: Sex: F M dd mm yy Marital Status: Single Married Common-law Divorced Widowed Street Address:
New Patient Intake Form. Name Birthdate Gender Last First Middle Initial. Address Street City State/Prov. Zip/Postal code
Dr. Kristi Tompkins, ND 5170 Golden Foothill Pkwy Suite 117 El Dorado Hills, CA 95762 P: (916) 235-6846 7563 Green Valley Road Placerville, CA 95667 P: (530) 622-23233 Fax: (530) 698-5127 www.doctorkristi.com
Dr. Kelly Gillis ND BPHE (Lic. 3095) Doctor of Naturopathic Medicine
Dr. Kelly Gillis ND BPHE (Lic. 3095) Doctor of Naturopathic Medicine Naturopathic Pediatric Intake Form (Child 0-13 yrs) Child s name: Parent/Guardian s name(s): Address: Age: Date of Birth: DD/MM/YYYY
Dr. Michelle Mackay Patel, ND
NATUROPATHIC PEDIATRIC INTAKE FORM (Birth to 12 years) PERSONAL INFORMATION: Child s Given Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: Gender: MALE / FEMALE Current Height/Length: Current Weight:
Dr. Jeannie Doig, HBSc, ND Naturopathic Physician Port Alberni (250)
Child Intake Form Child s name Age Date of Birth Date Sex M F Who is filling out this form (name and relation)? Contacts (in order of preference): Name Phone h Address w other Relationship to Child Name
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
What else would you like to see changed in his/her health?
Simmonds McMurrer Naturopathic Medicine Dr.Kali Simmonds,N.D. Dr.Lana McMurrer,N.D. Dr.Nara Simmonds,N.D. 34 Queen Street, 2nd Floor Charlottetown, PE C1A 4A3 Tel.902.894.3868 Fax.902.894.4054 www.simmondsmcmurre.com
II. Goal and Expectations (Please tell us your goals and expectations.) III. Childhood Illnesses (Please check those illnesses that you have had.
Natural Health and Wellness Center The path to a healthier, more vital you. PEDIATRIC HEALTH HISTORY QUESTIONNAIRE SUCCESSFUL HEALTH CARE AND PREVENTION ARE ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE
We look forward to seeing you. Please feel free to call us with any questions.
1227 E. 9th Street Edmond, OK 73034 Phone: (405) 475-0100 Fax: (405) 475-9275 https://susandimickmd.com Welcome to Dr. Dimick s Office. We appreciate the opportunity to provide your health care needs.
o Ongoing management of my
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
Dr. Anita Kieswetter BSc, ND Waterloo Naturopathic Clinic 22 McDougall Rd Waterloo, ON N2L 2W5 Tel: (519)
Dr. Anita Kieswetter BSc, ND Waterloo Naturopathic Clinic Welcome to Waterloo Naturopathic Clinic and the office of Dr. Anita Kieswetter BSc, ND. Congratulations on choosing naturopathic medicine as part
Dr. Michelle Mackay Patel, ND
NATUROPATHIC ADULT INTAKE PERSONAL INFORMATION: First Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: What is your current gender identity? Male Female Transgender Male/Transman/FTM Transgender
Do you currently have a family physician?: If not, where have you been getting health care?:
Adult Intake Form Preferred Location: Cambridge Kitchener Apply Patient Label here First Name: Last Name: Gender: Address: Phone number: Date of Birth: Health Card Number:_ Do you currently have a family
Medical Information Form
Fill in form with a computer Medical Information Form Child s Name: first name, last name Date of Birth: month, day, year Health Insurance information o Insurance group number, policy number, contact information:
N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M
N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M HEALTH SERVICES BASIC SCIENCES BUILDING VALHALLA, NEW YORK 10595 TEL 914-594-4234
PEDIATRIC HEALTH HISTORY FORM. Patient Name: DOB: / / Height: Weight: Lbs. Parent (s) Name: Address:
PEDIATRIC HEALTH HISTORY FORM Patient Name: Date: DOB: / / Height: Weight: Lbs Parent (s) Name: Address: Is there any other information about your child s health that you would like me to know? (Please
Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male
www.monctonnaturopathic.com 12 Fifth Street, Moncton, NB, E1E 3G9 Ph: 506-382-1329 Fax: 506-382-1828 Pediatric Intake Form (6-12 years) Name: Date: Age: Date of Birth: / / Gender (circle one): female or
Date of Birth Work Phone # ( ) Home Phone # ( ) Emergency Contact # ( )
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Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?
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NEW PATIENT INFORMATION *All information provided is kept in strict confidence
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Family Health History
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Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
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Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
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Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s
*All information provided is kept in strict confidence Child s Name: Date: Date of Birth: Age: Sex: male female Weight: Height: Girls: Age at first period: Address: Parents: Mother s Phone: (home) (cell)
Pavilion Pediatrics at Green Spring Station, P.A Falls Road, Suite 260 Lutherville, Maryland Phone (410) Fax (410)
Date Provider Patient Name: Pavilion Pediatrics at Green Spring Station, P.A. 10755 Falls Road, Suite 260 Lutherville, Maryland 21093 Phone (410)583-2955 Fax (410)583-2962 Patient Questionnaire Sex: Date
New Pediatric Patient Information
Arden Yingling, L.Ac., MAcOM (TX #AC01588) 9300 US 290, Austin TX 78736 512.640.9778 arden@songbirdacupuncture.com songbirdacupuncture.com New Pediatric Patient Information Child's Name Today s Date Birth