Pediatric Intake
Birth to Five Years
Name______________________________________ Date____________________
Age______________ Date of Birth________________ Sex: F__ M__
Mother/Guardian______________________________ Father/Guardian_______________________________
Address_____________________________________________________ State_______ Zip Code_________
Phone______________________ Alternate___________________
Person to Notify in Case of Emergency_________________________________ Phone____________________
Insurance_____________________ ID#__________________________ Group_______________
Medical Records (Doctors, Hospitals):____________________________________________________________
What are your child’s most important health problems? ______________________________________________
__________________________________________________________________________________________
Medications
Now
Past
Now
Past
Aspirin ____
____
Antibiotics
Tylenol ____
Inhalers ____
____
_____
Decongestants
_____ _____
____
Anti-histamine ____
_____
Ibuprofin
_____ _____
____
Asthma Meds
_____
Topical Steroids
_____ _____
Others_______________________________
____
Now
Past
_____ _____
Allergies to medications_______________________________________________________________________
Medical History
_____ Chicken Pox
____ Scarlet Fever
_____ Bronchitis
____ Tonsillitis, how many times? ____
_____ Measles
____ Pneumonia
_____ Rubella
_____ Ear infections, how many? _____
_____ Mumps
_____ Eczema
_____ Asthma
_____ Colds, how frequent? __________
_____Croup
_____ Other______________________________________________________________
Special Studies
When
Where
Results
Electroencephalogram ___________
___________________ __________________________________________
Psychological Exam
___________
___________________ __________________________________________
Hearing/Speech/Sight
___________
___________________ __________________________________________
X-Ray/MRI
___________
___________________ __________________________________________
Injuries/Surgeries/ Hospitalizations
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Immunizations
_____ measles _____ polio _____ MMR _____small pox _____ diphtheria _____ mumps _____ DPT _____tetanus
_____influenza _____ others______________________________
Any adverse reactions to immunizations _______________________________________________________________
________________________________________________________________________________________________
Family History
_____heart disease
_____arthritis
_____diabetes
_____tuberculosis
_____birth defects
_____allergies
_____cancer
_____hay fever
_____mental illness
_____ hypertension
_____eczema
Previous Pregnancies by natural mother, miscarriages or complications________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Birth History
Mother’s age at child’s birth__________
Mother’s health during pregnancy: _____bleeding
_____diabetes
______cigarettes, alcohol, drugs
Term of pregnancy: Full_____
Premature_____
_____hypertension
_____illness
_____thyroid problems
_____nausea
_____physical or emotional trauma
Late_____ Weight at Birth_____________
Length of labor_______________ Complications__________________________________________________________
As a baby, did your child have any of the following problems? _____jaundice
_____rashes
_____colic
_____birth injuries
_____fever
_____cerebral palsy
_____diarrhea
_____allergies
_____birth defects
_____blue baby
_____seizures
other___________________________________________________________________________
Feeding: breast fed_____ How long? _________
formula_____
milk/soy_____
Age began: solid foods__________ sitting___________ crawling__________ walking_________ first words__________
Child’s first year sleep patterns________________________________________________________________________
Symptoms
Please circle: Y = current condition
N = never had
P = had in the past
Hives
Y N P
Burning urination
Y N P
bloody urine
Y N P
Eczema
Y N P
frequent urination
Y N P
cries easily
Y N P
Bleeding gums Y N P
heart murmur
Y N P
nervous
Y N P
Nose bleeds
Y N P
vomiting spells
Y N P
sleep problems
Y N P
acne
Y N P
anemia
Y N P
night sweats
Y N P
high fevers
Y N P
stomach aches
Y N P
light sensitivity
Y N P
chronic rash
Y N P
jaundice
Y N P
body/breath odor Y N P
hearing loss
Y N P
easy bruising
Y N P
motion sickness
Y N P
diarrhea
Y N P
flat feet
Y N P
no appetite
Y N P
sore throats
Y N P
constipation
Y N P
nightmares
Y N P
gas
Y N P
frequent headaches
Y N P
frequent colds
Y N P
wheezing
Y N P
joint pains
Y N P
canker sores
Y N P
cough
Y N P
bleeding tendency
Y N P
unusual fears
Y N P
dizzy spells
Y N P
hair loss
Y N P
excessive fatigue Y N P
Any other condition?_____________________________________________________________________________
Diet
Please describe your child’s typical daily diet:___________________________________________________________
_______________________________________________________________________________________________
Any known food intolerances?_______________________________________________________________________