Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male

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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 male Mother's name: Father's name: Address: City: Province: Postal Code: Phone # (home): ( ) Parent s # (work): ( ) NB Medicare #: Parent s email address: Which is your preferred contact method for visit reminders (circle one)? email or phone Which is your preferred spoken language during office visits (circle one)? English or Français How did you hear about our clinic (be as specific as you can)? HEALTH HISTORY QUESTIONNAIRE What are your child's most important health problems? List as many as you can in order of importance: 1. 2. 3. 4. 5. Does your child have a contagious disease at this time? If yes, what? Y N Previous Illnesses Rheumatic fever Y N German measles Y N Chicken pox Y N Measles Y N Tonsillitis Y N approx. number Ear infections Y N approx. number Other Y N list 1

Has your child had any of the following tests? When Where Electroencephalogram (EEG).... Psychological evaluation Hearing tests Speech/Language tests Hospitalizations/ Surgeries/ Injuries What hospitalizations, surgeries or injuries has your child had? Immunizations Polio Y N Pertussis Y N Tetanus shot Y N Diphtheria Y N Measles/Mumps/Rubella Y N Influenza Y N Any adverse reactions? Y N If yes, what? Allergies Is your child hypersensitive or allergic to: Any drugs? Any foods? Any environmental? Breakfast: Lunch: Dinner: Snacks: To Drink: Typical Food Intake Please list any prescription medications, over the counter medications, vitamins or other supplements your child is taking: 1) 5) 2) 6) 3) 7) 4) 8) 2

REVIEW OF SYSTEMS Y = a condition now P = significant problem in the past N = never had MENTAL/ EMOTIONAL Mood Swings Anxiety/nervousness Irritability Cries easily Hyperactivity Unusual fears Introvert/extrovert Sleep problems Motion/car sickness Nightmares ENDOCRINE Heat/cold intolerance Fatigue Excessive thirst Excessive hunger Low blood sugar High blood sugar SKIN Rashes Eczema, Hives Acne, Boils Itching HEAD Headaches Head Injury Dizzy spells High fevers EYES Glasses or contacts Tearing or dryness Eye pain/strain EARS Earaches Impaired hearing NOSE AND SINUSES Frequent colds Nose Bleeds Stuffiness Hayfever Sinus problems Loss of smell MOUTH AND THROAT Frequent sore throat Canker sores Breath odor RESPIRATORY Cough Wheezing Asthma Bronchitis 3

CARDIOVASCULAR Heart disease Murmurs URINARY Frequent urination Bed wetting GASTROINTESTINAL Belching/passing gas Stomach aches Constipation Diarrhea Bowel Movements How often Breastfed? how long? Formula? milk / soy/ other MUSCULOSKELETAL Joint pain/stiffness Muscle spasms/cramps Broken bones BLOOD/PERIPHERAL VASCULAR Anemia Easy bleeding/bruising Is there any information about your child's health that you would like to add? What expectations do you have for your child from working with our clinic? Welcome! We're honored to be of service for you and your child! 4

5 www.monctonnaturopathic.com 12 Fifth Street, Moncton, NB, E1E 3G9 Ph: 506-382-1329 Fax: 506-382-1828 Declaration and Informed Consent for Naturopathic Care We would like to take this opportunity to welcome you. Your naturopathic doctor will conduct a thorough case history, physical examinations (when indicated) and may recommend specific blood, urinary or other laboratory reports as part of the treatment work-up. Your naturopathic doctor integrates supportive therapies like nutrition, herbal medicine, homeopathy, acupuncture, physical medicine and lifestyle counseling to assist the body s ability to heal and to improve the quality of life and health. Statement of Acknowledgement Printed name of patient: As a patient, I have read this information and understand that the form of medical care is based on naturopathic and other supportive principles and practices. I recognize that even the gentlest therapies potentially have their complications. The information I have provided in this intake form is complete and inclusive of all health concerns including possibility of pregnancy and all current medications, including over the counter drugs. Slight health risks of some naturopathic treatments include, but are not limited to: temporary aggravation of pre-existing symptoms; allergic reactions and other adverse effects to supplements, homeopathics or herbs; pain, fainting, bruising or injury from acupuncture, venipuncture or intramuscular vitamin injections; and muscle strains, sprains and spasms, disc injuries from spinal manipulations. I also recognize the following: I will be given the opportunity to discuss and consent to any treatment plan. Any treatment or advice provided to me as a patient is not mutually exclusive from any treatment that I may now be receiving or may in the future receive from another licensed healthcare provider. I am at liberty to seek or continue medical care from a medical doctor or other healthcare providers. It is highly recommended that I update my health care providers of any new treatments. I also confirm that I have the ability to accept or reject this care of my own free will and choice. I understand results are not guaranteed. I accept full responsibility for any fees incurred during care and treatment. I understand that a record will be kept of my visits. This record will be kept confidential and will not be released without my consent. I understand that I may look at my medical records at any time and can request a copy of them. I am responsible for payment at the time services are rendered. Dispensary items must be paid for in full before leaving the office. I am aware that 24 hours notice must be given for all cancelled appointments or a cancellation fee will be applied. I understand that your naturopathic doctor reserves the right to determine which cases fall outside of his scope of practice, in which case the appropriate referral will be recommended. I have read and understand the Privacy Policy which is available on the clinics website at www.monctonnaturopathic.com (see Forms). I consent to receive naturopathic treatment. I understand this consent is voluntary and may be revoked at any time. Signature of patient or guardian: Date:

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