Patient Name DOB Age Sex: Male Female. Address City State Zip. Parent or Guardian Contact Information. Relationship to Child

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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 Name Relationship to Child ( check box if address is same as above) Address City State Zip Home Phone Cell or Alternate Phone E-mail Parents are: Married Separated Divorced Common Law Other: How did you hear about us? Emergency Contact Name Phone Cell or Alternate Phone Relationship to Child Pediatrician Name Phone Address City State Zip Health Concerns Please list health concerns in order from most bothersome to least bothersome. Please include Mental, Emotional, and Physical concerns. 1) Length of Time 2) Length of Time 3) Length of Time 4) Length of Time 1 of 3

Eric Udell, ND 1250 E Baseline Rd., Suite 104 Laurinda Kwan, ND Birth History Previous Preg.(#) At time of conception: Mother s Age Father s Age Mother s Pregnancy History: Please check all that apply. Nausea/vomiting High Blood Pressure Anemia Preeclampsia Gestational Diabetes Thyroid Condition Bleeding Physical Trauma Infection Emotional Stress Coffee Smoking Recreational Drugs Alcohol Prenatal Previous Births(#) Prescription Medication (please list) Birth Did baby deliver on time? (If No, + weeks =, or weeks = ). Length of Labor Vaginal Birth or C-Section Babies birthweight (lbs) Length (in.) Were there any birth complications? Did you take a prenatal vitamin: Yes No Hospitalizations, Surgeries, and Major Illnesses Condition or Procedure Date 1) 2) 3) 4) Vaccination History Please check all that apply. HepB DTP Hib Polio MMR Varicella Other Any reactions or complications from vaccinations? Medications Please list all prescription and over-the-counter medications child is currently taking. Supplements Please list all supplements child is currently taking, including brand names. 2 of 3

Medication Dosage Supplement Dosage 1) 2) 3) 4) 1) 2) 3) 4) Health History Any known allergies to foods, medications, environmental or other allergy? Please describe. Now Past Now Past Now Past Asthma Gastric Reflux Chicken Pox Coughing/Wheezing Colic/Gas Mononucleosis 3 of 3

Eric Udell, ND 1250 E Baseline Rd., Suite 104 Laurinda Kwan, ND Eczema Teething Difficulty Mumps Hives Thrush Rubella Chronic Sniffles/Runny Nose Cradle Cap Pneumonia Frequent Colds Psoriasis Whooping Cough Strep Throat/Tonsillitis Diaper rash Jaundice 4 of 3

Anemia Stomach Aches Dental Cavities Cold Sores Diarrhea Epilepsy/Seizures Headaches Constipation Hyperactivity Ear Infections (# times): Bed-wetting Anxiety Very Sweaty Baby/Child Urinary Tract Infxn 5 of 3

Nightmares Hearing Test Normal: Yes No Not Tested Vision Test Normal: Yes No Not Tested Speech Difficulty: Yes No Past Learning Difficulty: Yes No Past How many times has the child taken antibiotics? Was child breastfed? If yes, for how long? When was solid food introduced? General If no, what formula? When did the following milestones occur: Rolling over First tooth Sitting Walking Talking Dressed self Allergies Family History Mother Father Siblings Grandparents Asthma Eczema 6 of 3

Diabetes Cancer Cardiovascular Disease Obesity Tuberculosis Mental Illness Other: 7 of 3

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