Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s
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1 *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) (work) Mother s Father s Phone: (home) (cell) (work) Father s Emergency contact: (name) (relationship) telephone: (home) (cell) Primary care physician: (name) (telephone) Address: Referred by: P. 1 of 7
2 Main concerns, in the order of priority, and date started: Can you trace the origin of any present condition to any particular circumstance? (e.g. accident, illness, grief, mental upset, etc.) Prescription medications, non-prescription medications and health supplements the child is currently taking: Name Dosage Condition treated Since when Other treatments or therapies: Name Frequency Since when Substances the child is using: Description Amount Description Amount Alcohol Chewing Tobacco Cigarettes Coffee Laxatives / Purgatives Pain Killers Recreational Drugs Sleeping Pills Tea Other Allergies: P. 2 of 7
3 Medical history Medical procedures, surgeries, hospitalizations, accidents and major trauma Date Description Vaccinations: Measles Mumps Rubella Pertussis Chicken Pox Flu Other Adverse reactions: Which of the following has the child experienced or is suffering from now: Abortion Colic Goitre Leukaemia Parasites Tonsillitis Alcoholism Constipation Hard to please Malaria Pneumonia Tuberculosis Allergies Convulsions Hay Fever Measles Rheumatic Fever Undescended testicles Anemia Depression Heart Murmur Mental problems Sexual Abuse Urticaria Appendicitis Diabetes Hepatitis Miscarriage Skin Disease Vision Asthma Diarrhea Herpes Mononucleosis Sinusitis Warts Bedwetting Breathing Digestive Hypertension Much crying Sleeping Ear Infections Influenza Mumps Speech Worms Whooping Cough Burns Eczema Injuries Nervousness Strep Throat Yellow Fever Cancer Epilepsy Jaundice Night Terrors Tantrums Other Chicken Pox Frequent Colds Kidney Disease No energy Teeth Cold Sores Gall Stones Learning Nosebleeds Thyroid problems P. 3 of 7
4 Child s Birth History Birth Weight: Rh Blood? Any complications during and/or after delivery? Number of hours in labour: Was the delivery: Normal Premature Caesarean Forceps aided At home In hospital Drug aided Difficult Was the child breastfed? If yes, for how long? Type of formula used? At what age was: milk introduced? solid foods? What foods were first introduced? Mother s Pregnancy History Did you have any problems conceiving? Did you have a stressful pregnancy? Did you experience any of the following? Anaemia Fatigue Nausea Vomiting Did you use any of the following during pregnancy? Alcohol Antibiotics Cigarettes Iron supplements Recreational drugs Sedatives Sleeping pills Other Did you undergo x-rays? Ultrasound? How much weight did you gain during pregnancy? Did you have any food cravings or aversions during pregnancy? If yes, what were they? During the pregnancy, did you suffer any shocks, traumas, or losses? If yes, explain P. 4 of 7
5 Family history: Ailments which may be present in your family history: Alzheimer s Diabetes Hypertension Mental problems Tuberculosis Alcoholism Depression Heart Disease Skin Disease Cancer Gonorrhoea Hepatitis Syphilis Relationship Age Diseases Age at death Mother Father Cause of death Brother(s) Sister(s) Children Maternal Grandmother Grandfather Aunts Uncles Paternal Grandmother Grandfather Aunts Uncles P. 5 of 7
6 Details about your Child s symptoms: What triggers the symptoms (mental, emotional and physical symptoms)? Does anything make the symptoms unique? What makes the symptoms better (i.e. hot/cold, eating, sleep, time of day)? What makes the symptoms worse? Is the child affected by the weather? How? Perspiration (odour, night sweats, profuse)? Body temperature: Sleep (falling asleep, waking, position): Average energy level during the day (0 = none, 10 = max.): Has the child lost any weight recently? How much? Is there anything else regarding the child s overall condition that we should know? P. 6 of 7
7 Do you give permission to share your child s information with other health care providers for purposes of medical evaluation? yes no (signature of parent or guardian) How did you hear about K-W Homeopathic Medicine and Wellness Clinic? Referral from Health Care Practitioner Internet Referral from family or friends Newspaper Public Health Talk Magazine St. Jacobs Farmers Market Event Other Thank you for taking the time to fill out this form! P. 7 of 7
NEW PATIENT INFORMATION *All information provided is kept in strict confidence
NEW PATIENT INFORMATION *All information provided is kept in strict confidence Name: Date: Address: Telephone: (home) (cell) (work) E-mail: Emergency contact: (name) (relationship) telephone: (home) (cell)
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:
! 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
Adult Naturopathic Intake Form
Alternative Health Empowerment, Inc. 670 Colonial Road, Suite 5 Memphis, Tennessee 38117 (901) 683-8200 / www.ahe4life.com Personal Information Date: Name: Age: Birth Date: Sex: M F Address: City: State:
Avicenna Acupuncture PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS)
PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS) Date: Address: City: State: Zip: Parents Name: Telephone (cell): Parent s work #: Parent s email address: Date of Birth: Gender: How did you hear about this clinic?
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 REGISTRATION FORM
MONTCLAIR HOMEOPATHY LLC Linda Corenthal Robins, M.D. Montclair, NJ 0704 Office 973-746-9888 www.montclairhomeopathy.com PEDIATRIC REGISTRATION FORM Referred by: Name Nickname Birth date Mother s Name
Sandra Cross RNCP, RBIE. First Name: Last Name: Age: Birth Date: Sex: Male Female
Sandra Cross RNCP, RBIE ADULT INTAKE FORM First Name: Last Name: Age: Birth Date: Sex: Male Female Street Address: City: Province: Postal Code: Phone: (Home) (Work) (Cell) May we leave a message? Yes No
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
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)?
Name: Gender: m F m M. Mother s full name: Telephone: (work) (mobile) Father s full name: Telephone: (work) (mobile) Name: Telephone:
Du La, ND# 1135 Jonah Lusis, ND# 1248 T: 416 598 8898 Pediatric Intake Date: Name: Gender: m F m M Age: D.O.B.: Address: City: Postal Code: Telephone: (home) E-mail: Mother s full name: Telephone: (work)
CARY HOLISTIC HEALTH, LLC. Thank you for scheduling an appointment with Cary Holistic Health. Maggie Thibodeau, ND
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THERMOGRAPHY CLINIC 1596 REGENT ST. SUDBURY, ON P3E 3Z6
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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:
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
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
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Paediatric Intake (0-12) George Tardik B.Sc, ND- Naturopathic Doctor
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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
tel: (905) fax: (905) CHILD Questionnaire (to be answered by the mother if possible)
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PLEASE NOTE: WE ARE A FRAGRANCE FREE BUILDING. *(Please circle answer where ever there is a multiple question.)
1 Dr. Stephen Maltais ND, Naturopathic Doctor 88 Dover Mills Road, Port Dover, ON. N0A 1N1 Phone: (519) 583-1234 E-mail: docmaltais@kwic.com www.dovernaturoapth.com INTAKE FORM FEMALE (16 years of age
Family Naturopathic Clinic Adult Intake and Consent Form
Health History Form (GENERAL) Name Birth-date Date MSP # Blood Type Address City Prov/State Postal Code Phone (home) Phone (work) best time to call Can we leave messages for you here? Y N Email Occupation
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
ARGYLE NATURAL HEALTH CENTRE NATUROPATHIC INTAKE FORM. Full Name: (First) (Middle) (Last)
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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:
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POPE JOHN PAUL II REGIONAL CATHOLIC ELEMENTARY CERTIFICATE OF IMMUNIZATION
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Child Intake Form. In case of emergency, contact: Relationship: Phone:
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