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PEDIATRIC INTAKE FORM
Today's Date:
Child's Name:
Age:
Parents Name:
Phone #: (work)
Address:
Sex :  Male Female
Height:
Weight:
(home)
(cell)
Who is filling out this form?
Whom does the child live with (if different from above)?
Who referred you?
Date of Birth
(pager)
Relationship
Other Health Care Providers
Name:
Name:
Name:
Type of Practitioner
Type of Practitioner
Type of Practitioner
Phone #
Phone #
Phone #
How would you describe your child's general state of health?
Excellent
What are your child's current health concerns, in order of importance?
1.
2.
3.
4.
How Long?
How Long?
How Long?
How Long?
Good
Prior treatment
Prior treatment
Prior treatment
Prior treatment
Current medications and supplements:
Medical History
Childhood Illnesses (please check off)
 Chicken pox
 Measles
 Rheumatic fever
 Ear infections
 Scarlet fever
 Mumps
 Frequent Colds
 Allergies
 Pneumonia
 Rubella
 Tonsillitis
 Asthma
 Other (describe)
Immunizations (please check off)
 Measles, Mumps, Rubella (MMR)
 Influenza
 Diphtheria, Pertussis, Tetanus (DPT)
 Chickenpox
 Smallpox
 Hepatitis
 Other
Any adverse reactions to the above immunizations (describe)?
Any previous hospitalizations or surgeries (describe)?
Family History
Do either parents have a chronic illness (if so describe)?
Indicate if a close relative (parent, grandparent, sibling) has had any of the following.
 Allergies
 Birth defects
 Asthma
 Heart Disease
Fair
 Poor
2
 Arthritis
 Cancer
 Hypertension
 Diabetes
Prenatal History
Mothers age at birth
# of previous pregnancies:
Mothers health during pregnancy? Excellent
Good
Fair
 Poor
Please check off any of the following that applied to the pregnancy:
 diabetes
 bleeding
 high blood pressure
 other
 thyroid problems
 nausea
 vomiting
 toxemia
 infections
 miscarriages
 physical or emotional trauma? (accidents, abuse, death in the family etc.)
During the pregnancy, did the mother use any of the following:
 Tobacco
 Alcohol
 Recreational drugs (list)
 Prescription medication (list)
 Over-the-counter medications (list)
 Vitamins/Supplements (list)
Birth History
Length of term: Full
Premature (# of wks)
How long was the labour?
Home or Hospital Birth?
Infant weight
Which of the following interventions took place, if any?
induction
pain medication
episiotomy
pitocin
C-section
epidural
What was the mother’s emotional state at the time of birth & after the birth?
Late(# of wks)
forceps
vacuum extraction
Neonatal History
Please check off any of the following that apply
respiratory distress
colic
rashes
poor feeding
jaundice
infections
anemia
other
Diet
How is/was your infant fed?
How long was the infant breast fed?
When were solids introduced?
Breast fed
Formula fed (milk or soy)