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PEDIATRIC INTAKE FORM
Today’s Date (M/D/Y): ____ /____ /____
Child’s Name: __________________________________________________
Gender: ________________ Birth Date (M/D/Y): ____ /____ /____
Age: _________ Grade: _________________
Who is filling out this form (Name, Relation)? ____________________________________________________________
CONTACT INFORMATION FOR PARENTS/LEGAL GUARDIANS (Who the child lives with):
Name(s): _____________________________________________________ Relation(s): __________________________
Address: ______________________________________ City: _______________________ Postal Code: _____________
Home Phone: ______________________ Work Phone: ______________________ Cell: ______________________
May we leave you messages regarding your clinic visits? Yes No
E‐mail: ____________________________________
How did you hear about our clinic? (Please circle & specify)
Internet
Phone Book
Walk-By
Advertisement: ____________________ Friend/Family Member: _____________________ Other: _________________
EMERGENCY CONTACT INFORMATION
Name: ______________________________________ Relation: _________________ Phone #: _________________
HEALTH CARE PROVIDERS
Pediatrician: ________________________________________________ Phone #: ______________________________
Medical Doctor: ______________________________________________ Phone #: ______________________________
Specialist: __________________________________________________ Phone #: _______________________________
Other: _____________________________________________________Phone #: _______________________________
HEALTH CONCERNS
When was your child’s last check‐up with a pediatrician or family doctor? ______________________________________
Please describe your child’s general state of health: Excellent
Good
Fair
Poor
Please list and briefly explain your child’s main health concerns, in order of importance to you:
______________________________________________________________ When started: _______________________
______________________________________________________________ When started: _______________________
______________________________________________________________ When started: ______________________
450 Bronte Street S. Milton, ON
www.rishmawalji.com
905-875-2288
2
Please list your child’s past major illnesses, injuries, surgical procedures, operations, hospitalizations:
______________________________________________________________ When started: _______________________
______________________________________________________________ When started: _______________________
______________________________________________________________ When started: ______________________
What screening tests has your child had (e.g. blood, xray, MRI, hearing, visual, behavioural etc.)?
__________________________________________________________________________________________________
NUTRITION
Was your child breastfed? Yes No
If Yes, how many months: ___________________________________________
Substitute Formula Used: _____________________________________________________________________________
If applicable, please describe the mother’s diet while breastfeeding by including foods typically enjoyed, food cravings,
foods avoided, and any reactions the baby had to the mother eating different foods: ____________________________
__________________________________________________________________________________________________
Did your child experience colic? Yes
No
Please describe the child’s weaning history including child’s age when started & finished and the child’s response:
__________________________________________________________________________________________________
Does the child have any dietary restrictions? (e.g. religious, vegetarian, vegan, etc):
__________________________________________________________________________________________________
How would you describe the child’s eating habits?
SLEEP HABITS
Where does this child sleep? Own Room
Parents’ Room
Other: _________________________________________
Child’s sleep patterns (during first year): _________________________________________________________________
Current sleep patterns: _______________________________________________________________________________
Does your child nap during the day? Yes No If yes, when is the nap taken and for how long? ______________________
450 Bronte Street S. Milton, ON
www.rishmawalji.com
905-875-2288
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Is there any history of bedwetting? Yes No ____________________________________________________________
Current bed time and waking time of your child: __________________________________________________________
Please describe how food was introduced to your child by filling out the following chart:
FOOD INTRODUCED
APPROXIMATE AGE
REACTIONS TO FOOD
(Earliest to Most Recent)
(Eg. 6, 9, 12, 18 months)
(Eg. Skin Rash, Diarrhea)
DEVELOPMENTAL MILESTONES
If applicable, at approximately what age were the following milestones reached?
SMILES
ROLLS OVER
CRAWLS
FIRST SENTENCE
DRESS THEMSELVES
GRASPS OBJECT
SAT ON OWN
WALK ON OWN
SCRIBBLES
TOILET TRAINED
RECOGNIZES A FACE
FIRST TOOTH
FIRST WORD
PLAYS PATTY CAKE
SLEEPS IN OWN ROOM
MEDICAL HISTORY
Please list which vaccines (immunizations) your child has had and approximately how old they were at each dose:
VACCINE
AGE(S) GIVEN
ANY ADVERSE REACTIONS OR CHANGE IN HEALTH OR
BEHAVIOUR
Diphtheria, Pertussis, Tetanus (DPT)
Polio (ITP)
Haemophilus Influenzae type B (HiB)
Pneumococcal (Pneu‐C‐7)
Measles, Mumps, Rubella (MMR)
Meningococcal C (Men‐C)
Chickenpox/Varicella (Var)
Hepatitis B (HB)
Human Papillomavirus (HPV)
DTP/ITP Booster (Tdap/IPV)
Tetanus/Diphtheria Booster (Td)
Influenza (Inf)
Other(s): _________________________
450 Bronte Street S. Milton, ON
www.rishmawalji.com
905-875-2288
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Roughly how many times has your child been treated with antibiotics? ________ Approximate date of last time: ______
Please list any known or suspected allergies (medicines, food, environmental, etc.):
__________________________________________________________________________________________________
Please list all CURRENT or PAST prescription and over‐the‐counter medications (e.g. cough syrup, antibiotics), vitamins,
mineral, herbal or homeopathic medicines your child has taken by filling out the chart below. If more space is required,
please attach a separate sheet.
MEDICATION
DOSAGE (AMT & # TIMES PER DAY)
LENGTH OF TIME TAKEN
APPROX. DATES
Please check (√ ) which childhood illnesses your child has had and approximate dates:
YES
WHEN
YES
Chicken Pox
Mononucleosis
Scarlet Fever
Croup
Mumps
Stomach Flu
Meningitis
Other: ____________________
WHEN
Growing Pains
Pneumonia
Strep Throat
Measles
Rheumatic Fever
Whooping Cough
Rubella
Other: ____________________
Please list any complications that arose from the above illnesses (if applicable):
__________________________________________________________________________________________________
Please list whether the child’s mother, father, siblings, maternal or paternal grandparents have the following conditions:
WHO?
Allergies
Diabetes
Liver Disease
Birth Defect
Bleeding Disorder
Cancer: __________
450 Bronte Street S. Milton, ON
WHO?
Anemia
Digestive Conditions
Mental Illness
Epilepsy
Heart Disease
Kidney Disease
www.rishmawalji.com
WHO?
Asthma
Eczema
Migraines
SIDs
Stroke
Other: ___________
905-875-2288
5
The following chart will provide a more complete picture of your child’s overall health. Please check (√ ) column C if your
child CURRENTLY has a symptom below and column P if they have had it in the PAST. If they have never had the
symptom, please do not check either box.
C
GENERAL
Fatigue
Significant Weight Loss
Significant Weight Gain
EYES
Blurred Vision
Double Vision
Redness
Discharge
Infection (e.g. Pink Eye)
CARDIOVASCULAR
Heart Murmurs
Weakness
Septal Wall Defects
RESPIRATORY
Wheezing
Cough
Asthma
Bronchitis
Difficulty Breathing
NOSE & SINUSES
Frequent Colds
Nosebleeds
Sinus Problems
MOUTH & THROAT
Difficulty Swallowing
Sore Throat
Gum Problems
Dental Cavities
Tonsillitis
HEAD
Headache
Head Injury
Cradle Cap
Lice
NEUROLOGIC
Seizures
Dizziness
Tingling/Numbness
450 Bronte Street S. Milton, ON
P
C
P
SKIN
Itching
Eczema
Psoriasis
Rash
Hives
Dryness
Acne
Poor Wound Healing
Warts
Thrush
Boils
EARS
Ear Infection
Discharge
Trouble Hearing
Ringing in Ears
HEMATOLOGY
Easy Bruising
Easy Bleeding
Past Transfusions
DIGESTIVE
Change in Appetite
Hernia
Vomiting
Nausea
Excessive Gas
Stomach Pain
Bloating
URINARY
Urinary/Bladder Infections
Constipation
Increased Urination
Blood in Stool
Fungal Infections
Bedwetting
Diarrhea
OTHER Please specify:
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905-875-2288
6
PERINATAL HISTORY
For the remainder of this form when given a choice of answers, please circle the answer which applies to you and your
child and expand on answers where applicable in the space provided.
Was your child adopted? Yes No
If yes, child’s age at adoption: _____________________
How was pregnancy achieved? (e.g. intercourse, IVF, AI, sperm donation, etc.): _________________________________
Was the pregnancy planned? Yes No
Age of Mother at Conception: _________ Age of Father at Conception: _________
Number of Previous Pregnancies: _________ Number of Previous Deliveries_________
Pregnancy Length (wks): _________ Labour Length (hrs): __________ Second/Pushing Stage Length (hrs): __________
Baby’s Height at Birth: _______________ Baby’s Weight at Birth: _______________ APGAR Scores: _______________
Where was the baby birthed? Home
Hospital
Who was involved in baby’s delivery?
OBGYN
How was baby delivered?
C‐Section
Vaginal
Water
Midwife
Other: __________________________________________
Family Doctor
Doula
Which pain medication was administered (if any)? ________________________________________________________
Who else was present for support during the delivery? _____________________________________________________
Please check all of the complications that occurred and procedures that were necessary during pregnancy and labour:
√
Placenta Previa
Placental Abruption
Breech Presentation
Premature Birth
Fetal Distress
Prolapsed Cord
Jaundice
Gel Induction
Suction Required
Vacuum Extraction
Cephalopelvic Disproportion (Head too big)
Failure to Progress/Labour Stalles
Hemorrahge
450 Bronte Street S. Milton, ON
√
Blue Baby
Birth Defects
Multiple Birt
Undescended Testes
Meconium
Episiotomy
Forceps
Pitocin Drip Induction
Oxygen Required
Incubator
Premature Rupture of Membranes
Articificual Rupture of Membranes
Other: _______________________________
www.rishmawalji.com
905-875-2288
7
Mother’s emotional state post‐partum (after delivery)? ____________________________________________________
Please list & describe severity of any health conditions the mother experienced during pregnancy (e.g. high blood
pressure, gestational diabetes, bleeding, infections, thyroid problems, severe nausea, anemia, trauma):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How would you describe the pregnancy?
_________________________________________________________________________________________________
Please list any physical or emotional traumas the mother experienced during pregnancy:
__________________________________________________________________________________________________
If the mother used any of the following during pregnancy, please indicate how much, how often and specific type:
Tobacco ______________________________________ Alcohol ____________________________________________
Recreational Drugs: _____________________________ Caffeine ____________________________________________
Please list ANY prescription, over‐the‐counter medications, vitamins, mineral, herbal or homeopathic medicines the
mother took during pregnancy by filling out the chart below. If more space is required, please attach a separate sheet.
NAME
DOSAGE (Amt and # of times/day taken)
Length of Time Taken
Approximate Dates
Tests performed during pregnancy (e.g. ultrasound, amniocentesis):___________________________________________
If the Mom works, at how many weeks into the pregnancy did the mother take maternity leave? ___________________
Thank you for taking the time to complete this form.
We look forward to seeing you both at your child’s first visit.
450 Bronte Street S. Milton, ON
www.rishmawalji.com
905-875-2288
8
INFORMED CONSENT
Naturopathic Medicine is the treatment and prevention of disease by natural means. Naturopathic Doctors assess the
whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, noninvasive techniques are generally used in order to stimulate the body’s inherent healing capacity. A number of different
approaches may be used throughout the course of treatment. Treatment modalities include diet, lifestyle counselling,
clinical nutrition (including supplementation), botanical medicine, homeopathy, Traditional Asian medicine and
acupuncture, hydrotherapy, and physical medicine.
Nutritional counselling and supplements are recommended to address deficiencies, treat disease processes, and
promote health. The benefits may include increased energy, increased gastrointestinal function, improved immunity,
and general well-being.
Botanical medicine is a plant based medicine that involves the use of herbal teas, tinctures, capsules, and other forms of
herbal preparations to assist in recovery from injury and disease.
Homeopathy is a form of medicine based on the Law of Similars – that is, the use of tiny doses of the very thing that
causes symptoms in healthy people. These minute doses of plant, animal, or mineral origins are used to stimulate the
body’s ability to heal itself. Homeopathy is a powerful tool that effects healing on a physical and emotional level.
Asian medicine includes the use of acupuncture, Eastern herbs and dietary changes to eliminate disease and balance
body functions. Acupuncture refers to the insertion of sterilized disposable needles through the skin into underlying
tissues at specific points on the body. Eastern herbs may be given in the form of pills, tinctures, or decoctions (strong
teas) to be taken internally or used externally as a wash. Acupuncture is not used in children under the age of 12.
Hydrotherapy refers to the use of hot and cold water applications to improve circulation and stimulate the immune
system.
Lifestyle counselling involves identifying risk factors and making recommendations to help optimize one’s physical,
mental, and emotional environment.
During your child’s initial visits, your Naturopathic Doctor will take a thorough case history and perform a
basic/complaint-oriented physical examination, and when indicated, take urine samples or perform other laboratory
testing.
If you have coverage for Naturopathic Medicine, you are responsible for billing your own insurance company – we will
provide you with all of the information necessary to send your claim for reimbursement.
Even the gentlest therapies may cause complications in certain physiological conditions this depends greatly on the
individual and the extent of the illness. Some therapies must be used with caution in certain diseases such as diabetes,
heart, liver or kidney disease. It is very important, therefore, that you inform your naturopathic doctor immediately of
any disease process that your child is suffering from as well as any medications (prescription or over-the-counter) that
he or she is taking.
450 Bronte Street S. Milton, ON
www.rishmawalji.com
905-875-2288
9
This is to acknowledge that I have been informed and I understand that:
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Any treatment or advice provided to my child as a patient of Rishma Walji N.D. is not mutually exclusive of any
treatment or advice that he or she may now be receiving or may in the future receive from another licensed
health care provider; I am at liberty to seek or continue medical care from a physician or surgeon or other health
care provider qualified to practice in Ontario.
I understand that the practitioner will answer my questions to the best of her ability. I understand that the
results are not guaranteed. I do not expect Rishma Walji N.D. to be able to anticipate and explain all risks and
complications. I will rely on her to exercise judgment during the course of treatment, which she feels is in my
child’s best interests, based on the facts known.
The treatment and therapies rendered or recommended by Rishma Walji N.D. may be different from those
usually offered by a medical doctor or other licensed health care provider.
I am responsible for making Rishma Walji ND aware of all health conditions and all other treatments that my
child is undergoing.
I understand and have read the terms of the Personal Health Information and Privacy Act (PHIPA) (summarized
below, under “personal information”) and understand that Rishma Walji, ND and The Healthy Family
Chiropractic & Wellness Centre abide by the stipulations as laid out in the Act. My child’s records are
confidential unless required by law.
I understand that my child’s health records may be used to contribute to medical research that may help
understand disease, treatment or clinical outcomes. No personal or identifying information will be used at any
time for such purposes.
There are some risks, however rare, to Naturopathic Medicine. These include but are not limited to:
- aggravation of pre-existing symptoms,
- allergic reaction to supplements or herbs,
- pain, bruising or injury from acupuncture,
- fainting or puncturing of an organ with acupuncture needles
I understand that the Naturopathic Doctor may prescribe supplements that can be purchased from our in-house
dispensary, health food store, or elsewhere of your choice. Most insurance companies do not cover supplements.
I understand that fees are to be paid at the time of consultation.
I understand that a fee will be charged for missed appointments or cancellations with less than 24 hours notice.
I have read and understand the above-stated policies and information. I intend this consent form to cover the entire
course of naturopathic treatment for my child’s conditions. I understand that I am free to withdraw my consent and to
discontinue participation in these procedures at any time.
I, ___________________________________, legal guardian of this patient AUTHORIZE the Naturopathic Doctor, Rishma
Walji, who has been engaged by me, to examine and administer naturopathic care and treatment to
_________________________________ whose relationship to me is as my ______________________________.
Patient Name (please print): _______________________________________________ Date: ________________________
Name of Parent or Guardian: __________________________________________________________________________
Signature of Parent or Guardian: _______________________________________________________________________
450 Bronte Street S. Milton, ON
www.rishmawalji.com
905-875-2288
10
FEE SCHEDULE
Initial consultation (60 minutes)
$ 160
Second consultation (30 minutes)
$ 80
Extended follow-up visit (45 minutes) – only if needed, discussed in advance
$ 120
Acute consultations (15 minutes) – only for current patients, as appropriate
$ 50
Note: Any appointment cancelled with less than 48 hours notice
$ 50
Diagnostic Testing - Blood and other lab tests are available in combination with consultations, please inquire about pricing.
Fees are payable by cash, debit, visa or mastercard at the end of each visit.
Any prescribed supplements or homeopathics are not included in the above fees.
Please note that these fees are not covered by OHIP, but they may be covered by your extended health care plan.
Contact your employer or insurance agent to inquire about naturopathic coverage.
PERSONAL INFORMATION
Your identity will be protected at all times and a record will be kept of the health services provided. Patients may look at
their medical record at any time and may request a copy of it (may be subject to copying fee). Privacy of your personal
information is an important part of our clinic while providing you with quality health care. We understand the
importance of protecting your personal information and are committed to collecting, using and disclosing your personal
information responsibly. We will try to be as open and transparent as possible about the way we handle your personal
information.
At this office Dr. Natalie MacDonald, acts as the Privacy Information Officer. All staff members who come into contact
with your personal information are aware of the sensitive nature of the information that you have disclosed.
Our privacy policy outlines what our clinic is doing to ensure that:
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Only necessary information is collected about you;
We only share your information with your consent;
Storage, retention and destruction of your personal information complies with the existing
legislation, and privacy protection protocols;
Our privacy protocols comply with privacy legislation and standards of our regulatory body, the
Board of Directors of Drugless Therapy – Naturopathy (BDDT-N).
450 Bronte Street S. Milton, ON
www.rishmawalji.com
905-875-2288