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):

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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 out this form? (name, relationhip): Address: City: Province: Postal Code: Telephone (W): Telephone (H): Mobile: May we leave messages regarding your visit? Email: Siblings (names and ages): 1. Emergency contact: Relationship: Telephone number: 2. Emergency contact: Relationship: Telephone number: 1. Healthcare Provider: Specialty/focus: Telephone: 2. Healthcare Provider: Specialty/focus: Telephone: 3. Healthcare Provider: Specialty/focus: Telephone: Date of last medical doctor visit: Date of last physical exam: Date of last blood work: How did you hear about the clinic? If referred, please state by whom: Has your child ever been treated by a Naturopathic Doctor before? If yes, for what reason(s)? Date of last visit to ND: Are there other therapies that the child is currently using? (chiropractic, physiotherapy, acupuncture, etc.) No Yes

2 Current Health History: Please list your child s main health concerns in order of importance: 1. 2. 3. 4. 5. Current weight: Current height: Was the child adopted? List all previously diagnosed medical conditions: Does the child receive regular agespecific physical exams? (height, weight, vision, hearing, etc.) Date diagnosed: Vaccination/Immunization record (check those that apply): Please note vaccinations in bold are considered routine as per the Ontario Childhood Immunization Schedule 2004 DPT (Diptheria, Pertussis, Tetanus) MMR (Measles, Mumps, Rubella) Gardasil/Cervarix (HPV Vaccine) Haemophilus Influenza B BCG (Tuberculosis) Hepatitis A Hepatitis B Polio Flu Vaccine Other: Pneumococcal Conjugate (Meningitis/Pneumonia) Meningococcal C Conjugate (Meningitis) Varivax/Varilrix (Chicken Pox) Rotarix TM (Rotavirus) Did any of your vaccines cause adverse reactions, if yes: Did your child have any of the following childhood illnesses? (check those that apply) Asthma Polio Roseola Ear infections Rheumatic fever Scarlet fever Measles Rubella (German measles) Whooping cough Mononucleosis Chicken pox Mumps Impetigo List all allergies (environmental, medication, supplement, foods), and reaction type:

3 Medication: Please list all prescription and non-prescription medication, including over the counter medication (allergy medication, aspirin, antacid, etc.) the child is taking : Medication: Dosage: Since: Reason: Has your child ever been prescribed antibiotics? Approximately how many prescriptions? Longest duration: Supplements: Please list any vitamin, mineral, or natural supplements the child is taking, with doses and brands: Supplement: Dosage: Since: Reason: Please list any past hospitalizations or surgeries: Approx. date: Please list any past injuries (fractures, concussions, sprains, hard falls, etc): Approx. date: Please indicate any painful or distressed areas: a. Left Right

4 Family Medical History: Please check the box if any condition applies to you and/or a member of your family. Circle to whom it applies: Self; F= father; M= mother; G = grandparent; S = sibling; C = child. Circle if condition is resolved (Past) or ongoing (Current). Condition Relation Date Condition Relation Date Alcoholism/ High blood drug addiction pressure Allergies Low blood pressure Anemia Hepatitis Arthritis (osteo High or rheumatoid) cholesterol Asthma Headaches Bladder/urinary Kidney disease disease Cancer Skin disease Diabetes Stroke Depression/ Thyroid mental illness disease Eczema Tuberculosis Epilepsy Osteoporosis Lung disease Others: Heart disease Prenatal History: Pregnancy weight gain: Mother s age at conception: Father s age at conception: Was your child conceived naturally? Did the mother experience any of the following If fertility interventions were used, pleased indicate: during pregnancy: excessive bleeding emotional trauma diabetes physical trauma Did the mother receive prenatal medical care? thyroid problems nausea high blood pressure vomiting Please check any of the following that the mother has used during pregnancy: Tobacco Prescription and over-the-counter medication (please specify dosage): Alcohol Recreational drugs Others: Supplements (please specify brand, dosage): Please rate the mother s general health during pregnancy: excellent good fair poor unknown How was the mother s diet during pregnancy? excellent good fair poor unknown The mother s diet during pregnancy was primarily: vegan vegetarian omnivore (both veg/meat) pescatarian (eats fish, but not meat) other:

5 Birth History: Term length: full-term premature weeks late weeks Birth weight: What type of delivery? vaginal c-section in-hospital home-birth Birth length: Length of labour: Were any delivery interventions used? The labour was: Any complications? Please describe: spontaneous induced If so, which of the following: Was the mother Strep B positive? episiotomy epidural forceps suction If yes, were antibiotics used during birth? Did the child experience any of the following at or after birth? jaundice seizures infections congenital conditions rashes birth injuries poor feeding other: Were any of the following used? silver nitrate vitamin K drops other: Dietary & Lifestyle Habits: Diet: Was your infant fed breast milk? If yes, for how long? Sleep/rest: At what age did your child first have solid food? Was your infant fed formula? If yes, what type/brand? What foods were introduced before 6 mos? At 6-12 mos? Which typical diet does the child eat: Vegan Vegetarian Omnivore (veg/meats) Pescatarian Other: Restrictions: Did your child ever experience colic? How severe? Mild Moderate Severe Any food intolerances/food allergies? How many bowel movements per day? How many times does the child urinate? Typical diet in 24 hours: Breakfast: Dinner: Lunch: Snacks: Beverages, and quantity: How many hours does the child sleep on average? Does the child nap? Does the child have trouble falling asleep? Child s usual sleep-time: Child s usual wake-time: Does the child have trouble staying asleep? Does the child: Snore Wet the bed Have nightmares Sleep walk Sleep talk

6 Social / Behaviour / Development How would you describe your child s behaviour/temperament with siblings/friends? Does your child enjoying playing/interacting with other children? Does your child have any learning disabilities? If so, please describe: Does the child exercise? How often does the child watch TV / play video games? If yes, how much on a daily basis, and less than 1 hr/day what forms/sports? 1 hr/day 2 hrs/day Any other extracurriculars activities? 2hrs+/day Environmental: Does anyone in the home smoke? Are there pets in the home? If yes, please list How would you describe the emotional climate at home? Describe the environment at school (performance, reports, bullying, etc): Do you know of any toxins or other hazards the child is regularly/might be exposed to? No Yes How is the child s home heated? Natural gas Oil Electric Wood Other: Is there anything that you feel is important that has not been covered?

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