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Naturopathic Intake Form - Pediatric
Patient Information
Name
*
First
Last
Date of Birth
*
YYYY dash MM dash DD
Gender
Male
Female
Non-Binary
Prefer not to disclose
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
*
Primary Parent / Guardian Information
Name
*
First
Last
Phone
*
Secondary Parent / Guardian Information
Name
First
Last
Phone
Emergency Contact
Name
*
First
Last
Phone
*
Family Doctor
Name
First
Last
Phone
Medical History
Current health concerns
Allergies and intolerances
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Childhood illnesses
Chicken pox
Red measles
Mumps
Rubella
Scarlet fever
Rheumatic fever
Strep throat
Pneumonia
Mononucleosis
Ear infection
Tonsillitis
Other
Other childhood illnesses
Current medications
Type
Drug Name
Dosage
Frequency
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Current supplements
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Immunizations
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Type
Date
Prenatal / Birth / Neonatal History
Birth weight
Gestation period
Was your child breastfed?
Yes
No
Length of time
Formula
Type
Length of Time
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Age at introduction of solid foods
First solid foods
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Favorite foods
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Hospitalizations, surgeries, accidents, serious injuries
Incident
Date
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Health History
Family health history
Identify all family members who have or have had any of the following
Alcoholism
Drug abuse
Anemia
Asthma
Eczema
Heart disease
Hypoglycemia
Obesity
Thyroid disorder
Allergies
Arthritis
Diabetes
Epilepsy
Hearing loss
Mental illness
Stroke
Other
Other family health concerns
Patient's health history
Allergies
Anemia
Asthma
Bedwetting
Birth Defects
Colic
Cough / wheeze
Croup
Depression
Diarrhea
Dry skin
Earaches
Eczema / rash
Fatigue
Frequent infections
Headaches
Heart murmur
High fever
Hyperactivity
Insomnia
Jaundice
Learning problem
Moodiness
Stuffy nose
Thrush
Vomiting spells
Other
Other previous health conditions
Consent and Signature
Consent
*
I verify the information I have provided on this form is truthful and accurate.
Parent / guardian signature
*
Email
This field is for validation purposes and should be left unchanged.
This is a preview of this form. No submissions will be received.