Confidential Pediatric Case History
Please help me to understand your child’s health needs by carefully completing this intake form.
All information is strictly confidential.
Patient Information:
Child’s Name: _____________________________________________________ Age: _____ Gender: __________
Date of Birth: ________________ ________ ___________ Care Card # (PHN): ___________________________
(Month)
(Day)
(Year)
Parent/Guardian Information:
Name: ____________________________________ Relationship: _____________ Phone: ___________________
Name: ____________________________________ Relationship: _____________ Phone: ___________________
Address: _______________________________________________ City: _________________________________
Province: _____________ Postal Code: _____________________ Phone: _______________________________
Contact in case of emergency: ______________________________ Phone: _______________________________
Child’s GP or Pediatrician: ________________________________
How did you hear about the clinic? _________________________
Please list all of your child’s known allergies (medications, foods, airborne, etc): ___________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Current Health:
Please list the reasons for your child’s visit:
1. ___________________________________________ 3. _____________________________________________
2. ___________________________________________ 4. _____________________________________________
What expectations do you have from this visit to our clinic? _____________________________________________
Please list any medications or natural supplements your child is presently taking: __________________________
________________________________________________________________________________________________
Current weight: __________ Current height: _________
How often does your child have a bowel movement? ___________________________________________________
How is your child’s energy? ☐Extremely Low ☐Barely Enough
☐Good
☐Excellent
☐Too High
Please describe a typical day of eating for your child:
Breakfast: _________________________________________________________________
Lunch: ____________________________________________________________________
Dinner: ____________________________________________________________________
Snacks/Beverages: __________________________________________________________
#404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648
Dr. Sapphire Vanderlip, ND | sapphirevanderlip.com
Medical History:
Please list any serious injuries/hospitalizations/illness/trauma, with brief details:
________________________________ Year: _________ ________________________________ Year: __________
________________________________ Year: _________ ________________________________ Year: __________
History of antibiotic use? Yes ☐ No ☐
Approximate dates: ________________________________________
IMMUNIZATIONS – What vaccines has your child had?
 MMR
 Polio
 Hep A
 DTaP
 HiB
 Hep B
Any adverse reactions to vaccinations?
Yes ☐
 Pneumo
 Men-c
 Rotavirus
 Chicken pox
No ☐ If yes, please describe: _________________________
Mother’s Health During Pregnancy
 Diabetes
☐ High blood pressure
 Thyroid condition ☐ Other _______________
☐ Severe morning sickness ☐ Smoking/alcohol/drug use
☐ Mother’s age at birth: ____
Birth History:
Term:
Birth:
☐Full
☐Vaginal
☐Premature
☐C-Section
☐Late
☐ Birth weight: ____________
Birth complications or interventions: _______________________________________________________________
Feeding: Breastfed? Yes ☐ No ☐
How long: _______________
When was food introduced? __________________________________
First foods: ________________________________________________
Family History:
Has anyone in your child’s immediate family been diagnosed with any of the following?
 Autoimmune condition
 Diabetes
 Heart Disease
 Cancer: type(s) _________
 Mental illness
 Thyroid disease
 Other __________
Overview of Body Systems:
Has your child had any of the following conditions in the past or currently:
 Allergies
 Anemia
 Colic
 Cough/Wheeze
 Dry skin
 Earache(s)
 Heart murmur
 High fever
 Asthma
 Bedwetting
 Croup
 Depression
 Eczema/rashes
 Insomnia
 Frequent infections  Jaundice
 Birth defects
 Diarrhea
 Headaches
 Stuffy nose
 Thrush
 Vomiting spells
 Other ________
 Learning problem(s)
Is there any other information that I should know about your child?
#404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648
Dr. Sapphire Vanderlip, ND | sapphirevanderlip.com
Consent to Naturopathic Treatment
Naturopathic medicine uses natural approaches to treat and prevent disease. Naturopathic doctors (NDs) take into account the
unique complexity of a person’s circumstances, including physical, mental, emotional, genetic, environmental and spiritual factors.
Therapeutic procedures include diet and lifestyle counselling, nutritional supplementation, herbal medicine, acupuncture, physical
manipulation, intramuscular injection therapy, intravenous vitamin/mineral/nutrient therapy and pharmaceutical medications.
During your first visit, Dr. Sapphire Vanderlip, ND will take a thorough medical history and perform any essential physical
examination or laboratory testing.
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:
-
Dizziness, soreness, inflammation, bruising, soft tissue injury
Temporary worsening of symptoms
There is an extremely small possibility for a stroke from neck manipulation. Patients will receive thorough screening prior
to neck manipulation
More serious complications are extremely rare.
I have read and understand the above statements regarding potential treatment side effects and understand that there may be
potential risks or side effects that Dr. Vanderlip cannot anticipate. I also understand that there is no guarantee for a specific cure
result. I understand that at any time I may (in writing) withdraw consent to any further treatment.
Patient Name
Guardian Signature
Clinic Policies
All personal and medical information is kept by Dr. Vanderlip at Lonsdale Naturopathic Clinic. Your information is not released
without written consent provided by you unless required by law.
I consent to discussing my child’s case through email if necessary
Fees:
60 minute Initial Pediatric Visit:
30 minute Follow-up Pediatric Visit:
15 minute Brief Follow-up Visit:
Yes ☐ No ☐
$140.00
$70.00
$35.00
I understand that if I miss an appointment or cancel with less than 24 hours notice, I may be charged for the missed appointment.
Guardian Signature
Date
Witness Signature
Witness Name
Welcome!
Thank you for taking the time to fill out this extensive questionnaire. Your time and care is appreciated.