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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Transcription:

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 Name: Father`s Name: Sex: Phone Number: Phone Number: Mailing Address: Family Doctor or Paediatrician Phone Number: How did you hear about the clinic? Reason for referral or presenting problems: Family History heart disease diabetes birth defects food intolerance hypertension arthritis asthma Crohn`s Disease cancer allergies mental illness

Pregnancy History Mother`s age at childbirth natural conception artificial fertilization miscarriage Mother`s Health During Pregnancy bleeding thyroid problems nausea hypertension physical or emotional trauma diabetes antibiotics other medication cigarettes, alcohol, drug consumption Baby s Position During Pregnancy optimal position complete breech transverse Birth History Term: Full Premature Overdue length of labour Type if Delivery normal vaginal vacuum forceps birth weight birth length head circumference Apgar scores c-section induced labor Kristeller maneuver (pressure from nurse on the belly near the end of the delivery) Medication During Labour yes no pain medication Tocolytics to slow or stop contractions labor inductions epidural Baby s Position During Delivery normal vaginal face up breech hand first hand by face misshapen skull / head

Umbilical Cord normal wrapped around neck cut immediately after birth short wrapped around body delayed cutting once pulsations stops long knot in cord When did your baby have his or her first meconium after birth? days. Infant Feeding History Formula, how long? Milk/Soy, how long? Breast, how long? Breast Preference Left Right Latching Well Biting Pinching Losing Vacuum Baby (mark C current and P for past symptoms) Has your baby had any of the following problems? breathing problems colic fever rashes / eczema reflux blue baby allergies diarrhea seizures jaundice constipation birth defects tilted head to one side right/ left birth injuries (other) Explain: Child (mark C current and P for past symptoms) Head and Neck headaches vision problems tilted head to one side hearing loss sore throats dental problems canker sores

Heart and Lung heart murmur frequent colds cough fever asthma difficulties breathing Digestive System diarrhea constipation stomach ache jaundice gas no appetite reflux Skin / Immune System rashes /eczema acne chronic rash allergies list all allergies and since when Skeletal System flat feet back pain joint pain scoliosis burning of urine bloody urine bed wetting anemia nose bleeds easy bruising bleeding tendency dizzy spells cries easily nervous sensitivity to light unusual fears motion /car sickness sleep problems nightmares night sweats excessive fatigue Other Sleeping Patterns How many hours? day night Food intolerances (if any): Age began: solid food: Age began: sitting: crawling walking

Please describe your child`s typical diet? Medications (N For Now And P For Past) antibiotics pain killer other supplements list all Medical History Childhood Illnesses (Please Check Those Which Your Child Has Experienced) chicken pox frequent colds measles rheumatic fever mumps tonsillitis rubella ear infections scarlet fever others (please list) pneumonia Injuries / Surgeries / Hospitalizations (including date(s))

Immunizations measles diphtheria influenza polio mumps MMR DPT smallpox tetanus Reactions to Vaccinations? Yes No If yes describe the reaction or change from your child after vaccination. Missed appointment and cancellation Policy: We require at least 24 hours notice for cancellation of appointments. As we have set aside the appointment time for you, should you cancel an appointment without adequate notice or if you do not show for your appointment, you will be billed directly for 50% of the amount. All cancellations and appointments should be made by phone. Please note that health insurance plans do not cover missed appointments and therefore receipts for such cannot be submitted to your insurance company for reimbursement. Name: Signature: Date: 69 Cedar Street, P O Box 207, Windsor, NS, B0N2T0 1(902) 472-3510

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