Confidential Pediatric Intake Questionnaire

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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!
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