Avicenna Acupuncture PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS)
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- Donna Jacobs
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1 PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS) Date: Address: City: State: Zip: Parents Name: Telephone (cell): Parent s work #: Parent s address: Date of Birth: Gender: How did you hear about this clinic? Has any other family member already been a patient at this clinic? Name of doctor s office/hospital/clinic where your child s health records are kept: Reason for referral or presenting problems: MEDICATIONS NOW: Aspirin Tylenol Antibiotics Ibuprofen Decongestants Anti- histamine PAST: Aspirin Tylenol Antibiotics Ibuprofen Decongestants Anti- histamine MEDICAL HISTORY Allergies to medicines: Chicken pox Measles Mumps Rubella Pneumonia Scarlet fever Frequent colds Rheumatic fever Tonsillitis, approx no. of times: Ear infections, approx no. of times: Strep throat, approx no. of times: Other: 1
2 Has your child ever had any of the following? WHEN WHERE RESULTS Electroencephalogram (EEG): Psychological evaluations: Hearing test: Speech/language tests: Injuries/surgeries/hospitalizations (please list): IMMUNIZATIONS MMR Measles Mumps Rubella DPT Diphtheria Tetanus Polio Chicken pox Flu Others: FAMILY HISTORY Heart disease Hypertension Cancer Mental illness Diabetes Arthritis Osteoporosis Allergies Birth defects Asthma Tuberculosis Other significant: PRENATAL HISTORY Bleeding Illnesses Medications BIRTH HISTORY Nausea Hypertension Diabetes Previous pregnancies by natural mother, miscarriages, or complications? 2
3 Mother s health during pregnancy: Physical or emotional trauma Cigarettes, alcohol, drug consumption Thyroid problems Term: Full Length of labor: Complications: Did your child have any of the following problems shortly after birth? Premature Late Weight at birth: Rashes Jaundice Colic Other: Child s sleep patterns (1st year): Please describe hours of sleep per night and day: Age began: Sitting Crawling Walking Talking SYMPTOMS Hives Cries easily Nose bleeds Acne Jaundice Diarrhea Flat feet Nightmares Wheezing Dizzy spells Fever Blue baby Birth defects Allergies Cough Burning urine Bleeding gums Vomiting spells Anemia Sensitive to light Hearing loss No appetite Frequent colds Joint pains Bloody urine Heart murmur Sleep problems Night sweats Chronic rash Easy bruising Constipation Body/breath odor Bleeding tendency Unusual fears Excessive fatigue Frequent urination Cerebral palsy Birth injuries Seizures 3
4 How many bowel movements per day? What quality is it? (please mark all that apply) Firm dry runny smelly dark brown light brown yellowish, green no/light smell other: What color is the urine? Dark yellow light yellow no color DIET Breast fed: How long: Formula: Type (milk, soy): Age began solids: Which foods: Please describe your child s typical daily diet: Breakfast: Lunch: Dinner: Snacks: To drink: Food intolerances: How is your child s appetite? Good Fair Poor General Is your child at daycare/preschool/school? Yes No If yes: how many days per week? 4
5 What is you child s energy level? High Medium Low Describe your child s mood? Sleepy Agitated Restless Crying Happy Needy Other: What is your main concern regarding your child? (e.g. not getting enough nutrition, appears unhappy, not keeping up with other kids) THANK YOU. WE LOOK FORWARD TO HELPING YOUR CHILD IN ANY WAY WE CAN. 5
Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
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
First Name: Last Name: Date: Address: City: State: Zip:
Lachman and Associates 1432 Easton Rd, Suite 3G Warrington, PA 18976 P: 267-406-0782 F: 888-972-5592 Children s Intake: 0-12 years of age First Name: Last Name: Date: Address: City: State: Zip: Preferred
Children s Intake: 0-12 years of age
Julie Lachman, ND 196 W. Ashland St. Doylestown, PA 18901 phone: (267) 895-1733 fax (888) 972-5592 Children s Intake: 0-12 years of age First Name: Last Name: Date: Address: City: State: Zip: Preferred
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:
tel: (905) fax: (905) CHILD Questionnaire (to be answered by the mother if possible)
70 Queen St. S. Mississauga Ontario L5M 1K4 tel: (905) 826-1768 fax: (905) 286-5856 CHILD Questionnaire (to be answered by the mother if possible) Child s Name: Parents: Address: Phone: (day) (eve) Parents
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
Head to Heal Centre for Naturopathic Medicine & The Bowen Technique
Head to Heal Centre for Naturopathic Medicine & The Bowen Technique CHILDREN S QUESTIONNAIRE (To be completed by parent/guardian) Date: Child s Name: Mother s/guardian s Name: Mother s/guardian s Occupation:
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
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:
Naturopathic Family Physician
Are you ready for a new way to look at your health and your life? Are you looking for a dynamic medicine that treats YOU rather than your symptoms? Welcome to the and our private medical practice that
! Head to Heal Family Wellness Centre for Naturopathic Medicine & The Bowen Technique
Head to Heal Family Wellness Centre for Naturopathic Medicine & The Bowen Technique CHILDREN S QUESTIONNAIRE (To be completed by parent/guardian) Date: Child s Name: Mother s/guardian s Name: Mother s/guardian
NATUROPATHIC CHILD INTAKE FORM (0-12 years old)
NATUROPATHIC CHILD INTAKE FORM (0-12 years old) Please fill out this form as accurately and completely as possible. Completing this overview will help to obtain a more complete understanding of your child.
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)?
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
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
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)
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
Pediatric Intake Form
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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
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
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PEDIATRIC REGISTRATION FORM
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Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
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Child Intake Form. In case of emergency, contact: Relationship: Phone:
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Paediatric Intake (0-12) George Tardik B.Sc, ND- Naturopathic Doctor
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Name: Gender: m F m M. Mother s full name: Telephone: (work) (mobile) Father s full name: Telephone: (work) (mobile) Name: Telephone:
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OKANAGAN HEALTH & PERFORMANCE Inc.
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NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM
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Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
Pure Health Natural Medicine
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Health History Summary
Health History Summary Date Name: Age: Birthdate: Blood Type: Address: City: State: Zip: Home/Cell Phone: Work Phone: Email: Marital Status: # of Children: In case of emergency: Relationship: Tel: Whom