Confidential Pediatric Intake Questionnaire Successful health care and preventive medicine are possible when the physician has a complete understanding of the patient physically, mentally and emotionally. Please complete this questionnaire thoroughly and with care as this will help me determine the most effective treatment plan for you. If you have any questions, note them with a question mark. Thank you! Patient Information: Name: __________________________________ __________________________________ ________________________________ (First) (Last) (Alternate/Preferred Name) Date of Birth: ________________________ ___________ ____________ Age: ___________ Gender: ______________________ (Month) (Day) (Year) Parent/Guardian Information: Name: ____________________________________________________________ Relationship: ______________________________ Name: ____________________________________________________________ Relationship: ______________________________ Address: _____________________________________________________________________________________________________ City: __________________________________________________ Province: _________________ Postal Code: ______________ Phone: ________________________________________ E-mail: _____________________________________________________ Please describe the make-up of your child’s household (parents, siblings, multiple housholds etc.): ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Patient’s GP or Pediatrician: _________________________________________________ Phone: _____________________________ How did you hear about Lonsdale Naturopathic Clinic? ______________________________________________________________ Does your child have any known severe allergies or emergency information we should know about? Yes ☐ No ☐ If yes, please list: _______________________________________________________________________________________________ Current Health Please list your child’s most important health concerns/reasons for coming in: 1. ___________________________________________________ 3. ___________________________________________________ 2. ___________________________________________________ 4. ___________________________________________________ What expectations/goals do you and your child have from this visit to our clinic? What long-term expectations do you have for your child’s state of health? Please list any medications/supplements/remedies your child is presently taking: _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Current weight: _________________________ Current height: ___________________________ Percentiles: __________________ Allergies: ______________________________________________________________________________________________________ Dietary restrictions: _____________________________________________________________________________________________ How often does your child have a bowel movement? _________________________________________________________________ How much water does your child drink daily? __________________ Sleep: Hours per night: ____________________ Bedtime: ______________ Awake at: _____________ Naps: Yes ☐ No ☐ Regular exercise? Yes ☐ No ☐ Please describe: ______________________________________________________________ Please describe your child’s temperament: __________________________________________________________________________ How is your child’s energy? ☐Extremely Low ☐Barely Enough ☐Good ☐Excellent ☐Too High #404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648 Dr. Amy Rolfsen, ND | amyrolfsen.com What behaviours do you and your child engage in regularly that you believe are supportive to your health goals? _____________________________________________________________________________________________________________ What behaviours do you and your child engage in regularly that you believe are counterproductive to your health goals? _____________________________________________________________________________________________________________ What potential obstacles do you foresee on the way to your child’s health goals? _____________________________________________________________________________________________________________ What does your child LOVE to do? What are his/her hobbies and interests? _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Medical History Please briefly indicate the occurrence of the following (with dates): Please list any serious injuries/hospitalizations/illness, with brief details: _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Any other significant history/trauma from your child’s past: ___________________________________________________________ _______________________________________________________________________________________________________________ IMMUNIZATIONS – please check all that apply MMR Polio Hep A Pneumococcal Rotavirus DTaP HiB Hep B Men-c Chicken pox Any adverse reactions to vaccinations? Yes ☐ No ☐ If yes, please describe: ________________________________________ _______________________________________________________________________________________________________________ PRENATAL HISTORY Mother’s age at birth: ______________ # of previous pregnancies: ___________ Regular health check-ups: Yes ☐ No ☐ Describe mother’s health during pregnancy: _________________________________________________________________________ _______________________________________________________________________________________________________________ BIRTH HISTORY Term: ☐Full ☐Premature (# weeks: ________ ) ☐Late: (# weeks: __________ ) ☐Vaginal ☐C-Section ☐Induced ☐Anaesthesia used ☐Antibiotics used Birth: Please list any birth complications: ________________________________________________________________________________ Feeding: Breastfed? Yes ☐ No ☐ How long: _____________ Formula? Yes ☐ No ☐ Type: _____________________ Please describe any breastfeeding issues: ___________________________________________________________________________ Family History Please briefly list health history of family members, including heritable conditions such as cancer, diabetes, auto-immune disease, heart conditions, mental illness, arthritis, asthma etc. Family Member Mother Maternal Grandmother Maternal Grandfather Father Paternal Grandmother Paternal Grandfather Siblings Other Age if Alive Age at Death Conditions #404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648 Dr. Amy Rolfsen, ND | amyrolfsen.com Overview of Body Systems Please check any boxes that are current or recurrent concerns General Weight change Poor sleep Headaches Chills/fevers Sweat easily Cravings Sudden energy changes Delayed speech Delayed development Learning disability Birth Defects Eyes, Ears, Nose, Throat Dizziness Hearing loss/impairment Ear wax buildup Visual loss/impairment Loss of smell Ear aches/infections Ringing in ears Sinus infections Post-nasal drip Sore throats Cataracts Night or colour blindness Nosebleeds Eye strain/blurry vision Bags under eyes Mercury fillings Sores/lumps in mouth Chronic bad breath Tooth problems Too much/little saliva/tears Sore lips/tongue Canker sores Respiratory Difficulty breathing Chronic cough Coughing Blood Sputum/phlegm Pneumonia/bronchitis Asthma Allergies (pollen, pets) Cardiovascular High/low blood pressure Irregular heartbeat Dizziness/fainting Blood clots Chest pain Anemia Cold hands/feet Swelling of limbs Murmurs Easy bruising/bleeding Skin and Hair Rashes/itching/hives Acne Hair loss Weak/brittle nails Irregular moles Eczema/Psoriasis Dry skin Immune System Frequent illness Never get sick Chronic congestion Reaction to vaccination Bleed/Bruise Easily Past antibiotic use Swollen glands Auto-immune condition Genito-urinary Pain on urination Frequent/urgent urination Urinary incontinence Waking to urinate Recurrent urinary infection Sores on genitals Incontinence Bedwetting Blood in urine Colour/odor? ___________ Neurological Poor memory Balance/coordination problems Numbness/weakness Seizures Tremors Concussion/head injury Facial pain/tics Musculoskeletal Muscle pain Joint pain Bone pain Muscle spasm/cramps Broken bones Jaw pain/clicks Male Testicular pain/mass Paraphimosis/phimosis Female Early onset menstruation Vaginal discharge Emotional Chronic anger/frustration Unresolved grief Irritability/quick temper Very susceptible to stress Mood swings Hyperactivity Anxiety Depression Alcohol/Drug abuse Emotional eating Insomnia Nightmares Antisocial behaviour Unusual fears Diagnosed mental illness Considered/attempted suicide Gastrointestinal Nausea Vomiting Loss of appetite Abdominal pain Heartburn/reflux Belching Gas/Flatulence Gallbladder concerns Liver concerns Poor nutrient absorption Laxative/suppository use Blood in stool Undigested food in stool Diarrhea Constipation Rectal pain Itching/burning anus #404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648 Dr. Amy Rolfsen, ND | [email protected] | amyrolfsen.com Consent Form Dear patient: Naturopathic examination includes: physical and clinical diagnosis, traditional Chinese medical diagnosis and lab work. Therapeutic procedures include: homeopathy, spinal adjustment, botanical medicine, acupuncture, clinical nutrition, lifestyle counselling and Intramuscular Injection Therapy. Occasionally, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing complications are minimal, it is the practice of this clinic to inform our patients about them. These complications may include, but are not limited to: soreness, inflammation, soft tissue injury, dizziness, burns, bruising, stroke, and temporary worsening of symptoms. More serious complications are extremely rare. I have read and understand the above statements regarding potential treatment side effects. I also understand that there is no guarantee or warranty for a specific cure result. I understand the visit costs for Naturopathic treatment are as follows: Initial Pediatric Consultation $140.00 The Initial visit is 60 minutes with Dr. Rolfsen Subsequent Pediatric Consultation $70.00 Subsequent visits are 30 minutes with Dr. Rolfsen Subsequent Brief Pediatric Consultation $35.00 Subsequent brief visits are 15 minutes with Dr. Rolfsen I understand that if I miss an appointment or cancel on short notice (less than 24 hours), I may be charged a fee for the missed appointment. Signature x____________________________________________ Date x_______________ Doctor’s Signature x____________________________________ Date x________________ PARENTAL CONSENT If you are under the age of 19 parent consent is required for naturopathic treatment. Signature of Parent/Guardian x____________________________ Date x________________ Welcome! Thank you for taking the time to fill out this extensive questionnaire. Your answers will help us decipher what is going on so we can come up with the steps that will lead you to vibrant health!