480 Fisher St., Suite 100
North Bay, ON P1B 9M9
B: 705.497.8788
F: 705.497.8840
PEDIATRIC INTAKE FORM
Date: ___________________________________________
Name: ____________________________________ Gender: M / F
Date of birth: ____________________________________
Parent/ Legal Guardian Name: ________________________________
Email Address: ___________________________________
Address: __________________________________________________
Health Card Number: _______________________________ Adopted: Y / N
Phone (Home): ___________________________________
(Work): _________________ (Cell): ____________________________
Medical Doctor: ___________________________________ Height & Weight: __________________________________________
Child live with Parents? Y / N
If no, explain ______________
Emergency Contact:
NAME:______________________________________________________________________
ADDRESS:____________________________________________________________________
PHONE: _____________________________________________________________________
OFFICE USE ONLY:
Who Referred You to this Clinic?
____________________________________________________________________________
PRIMARY HEALTH CONCERNS
1. ___________________________________________________________________________________________________________
2. ___________________________________________________________________________________________________________
3. ___________________________________________________________________________________________________________
4. ___________________________________________________________________________________________________________
Others: ______________________________________________________________________________________________________
How did these conditions develop? Are there any specific events (surgeries, drug
reactions, accidents, food, etc.) that you can identify that caused or have
aggravated these conditions? What has improved these conditions?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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MEDICATIONS: (Past or current):
Prescribed medications:
Purpose
Dose
Side Effects
Supplements (vitamins & minerals, herbs, homeopathics)
Current
ALLERGIES or SENSITIVITIES
Allergy to:
Past
Past
Current
Time of Onset
Medications
Supplements
Foods
Environment
PAST SURGERIES/ HOSPITALIZATIONS
Surgery/hospitalization Dates
1.
Hospital/Clinic
Reason
2.
3.
ILLNESSES/ Review of Systems
(Please put an N if your child has the condition now, P for in the past, B for both)
Chicken Pox ________
Polio ______________
Scarlet Fever _______
Seizures ___________
Strep Throat ________
Croup _____________
High Blood Pressure __
Ulcers _____________
Indigestion/ Gas _____
Diphtheria _________
Whooping Cough ____
Rheumatic Fever_____
Vision Problems _____
Tonsillitis __________
Pneumonia ________
Frequent infections __
Freq. headaches ____
Diarrhea ___________
Rubella (German/3day) _____
Mononucleosis ____________
Severe Head Injury _________
Frequent Runny Nose ______
Recurring Ear Infections _____
Coughing/ Wheezing _______
Influenza _________________
Herpes (oral) ______________
Colitis ___________________
Measles (2 wk) ______
Roseola ___________
Dizziness __________
Nosebleeds ________
Asthma ____________
Pleurisy ___________
Fevers ____________
Eczema ___________
Vomiting __________
Mumps ______
Headache ____
Cradle Cap____
Earaches _____
Bronchitis ____
Heart murmur_
Acne ________
Constipation __
Jaundice _____
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Bed wetting ________
Paralysis ___________
Hypoglycemia ______
Hives _____________
Sore Throats _______
Talks in sleep ______
Hearing Loss _______
Motion sickness ____
Bladder infection ____
Cerebral Palsy_______
Hypothyroid _______
Chronic Rash _______
Frequent Colds _____
Bruises easily ______
Stomach aches _____
Sensitive to light _____
Meningitis _______________ Encephalitis ________ MS __________
Anemia __________________ Cancer ____________ Diabetes _____
Hyperthyroid ______________ Anxiety ____________ Fears________
Hair loss _________________ Excessive Fatigue ____ Nervous _____
Burning urination __________ Nightmares ________ Cries easily ___
Dizzy spells _______________ Cough ____________ Wheezing ____
Bleeding gums ____________ Body odour_________ Bad breath ___
Other (specify) ______________________________________________
PRENATAL HISTORY – mother’s health during pregnancy
Has the child’s mother had any occurrences of miscarriages, stillborns, abortions, or difficulty conceiving? Y / N
If yes, describe: _____________________________________________________________________________________
Please place a check mark beside any of the following pregnancy complications, if they occurred:
Nausea _______ Vomiting _______ Hypertension _______ Diabetes _______ Pre-eclampsia_______ Bleeding ________
Describe mother’s diet during pregnancy, any food cravings? ________________________________________________
__________________________________________________________________________________________________
What medications/supplements did the mother take during pregnancy? _______________________________________
__________________________________________________________________________________________________
Did the mother smoke prior to or while pregnant? Y / N
If yes, what amount: ______________________
Did the mother use drugs or alcohol? Y / N
If yes, type and amount: ___________________
While pregnant, did the mother have any medical or emotional difficulties? Describe: ___________________________
Did the mother have any infections (e.g. colds/flus/vaginal infections etc.) during pregnancy? If yes, what type?
__________________________________________________________________________________________________
Length of pregnancy (weeks): __________________________________________________________________________
Length of labour: _________
Induced Y / N
Caesarean Y / N
Interventions used (forceps, vacuum) Y / N
Describe any complications for the mother or the baby during delivery or after the birth:
__________________________________________________________________________________________________
Baby’s birth weight: _________________________
Baby’s birth length: _____________________________
PRENATAL HISTORY-Father’s health before conception
Did the father smoke prior to or during pregnancy? Y / N
Did the father use drugs or alcohol preconception? Y / N
If yes, type and amount: ______________________________________________________________________________
In what way was the father involved in the pregnancy?_____________________________________________________
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DIET HISTORY:
If breast-fed, how long? __________________________
Age solids foods introduced: ______________________
If formula fed, how long? ________________________
Any adverse reactions? __________________________
How is your child’s appetite in general? ___________________ Is your child a picky eater? Y / N
List the primary foods included in your child’s diet: ________________________________________________________
__________________________________________________________________________________________________
List the foods you exclude from your child’s diet: __________________________________________________________
List any food cravings: ________________________________
Amount of liquid your child drinks each day __________
IMMUNIZATION RECORD
Vaccination
Date
Adverse Reactions
Diphtheria, Tetanus, Pertussis DPT)
Oral Polio Vaccine (OPV)
Measles, Mumps, Rubella (MMR)
Hepatitis
Hib
Influenza
Meningoc.
Varivax
Flu
DENTAL HISTORY
Was the process of teething difficult for your child? Y / N
Has your child been to the dentist?
Y/N
Does your child have any metal fillings?
Y/N
Describe,______________________________________
Describe any dental work done: ___________________
DEVELOPMENTAL HISTORY
Please note the age at which the following behaviours took place:
Weaned:
Sat Alone:
Crawled:
_______________ _______________ _______________
First Teeth:
_______________
Walked:
_______________
Compared to others in the family, child’s development was: Slow ______ Average ______ Fast ______
In what ways: _________________________________________________________________________
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BOWEL/URINARY HABITS
Frequency of stool: _______________________________ Does your child have pain on passing stool? _____________
Have you noticed any abnormalities in your child’s stools? (colour changes, consistency, undigested foods)
__________________________________________________________________________________________________
Does your child experience any urinary symptoms? ________________________________________________________
SLEEP HISTORY
Does your child have trouble falling asleep? Y / N
Please check if your child experiences any of the following while sleeping:
Uninterrupted __________ Wakes often/ Restless _________ Nightmares _________ Wakes for reassurance _________
Wakes for food _________ Calm _______________________Awakes well rested ____ Awakes tired/irritable _________
Night Sweats___________
Temperature of your child while sleeping is generally (circle): HOT COLD NEITHER
If nightmares, what is the theme? _______________________ What position does your child sleep in? _____________
FAMILY HEALTH HISTORY
Mother
Father
Siblings
Age
If Deceased, age at death & cause
of death?
Please place a check mark beside the conditions that have occurred among the child’s relatives
Allergies ___________ Asthma ____________ Anemia ____________ Arthritis ___________ Alcoholism__________
Bleeding tendency ____ Blindness __________ Cancer _____________ Deafness ___________ Diabetes __________
Depression__________ Eczema _____________ Glaucoma _________ Gout ______________ Heart disease _______
High blood pressure __ Hypothyroid _________ Hyperthyroid _______ Kidney disease ______ Mental illness _______
Mental retardation ___ Migraines ___________ Multiple Sclerosis ____ Muscular Dystrophy __ Nervousness ________
Perceptual motor disorder _________________ Seizure/epilepsy _____ Stroke _____________ Tuberculosis ________
Anxiety ____________ Glaucoma ___________ Smoking ____________Other (specify): __________________________
Thank you for taking the time to fill out this intake form. Full completion ensures better healthcare for your child!
We look forward to working with you and your family on your path to wellness.
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