PEDIATRIC INTAKE FORM
Patient’s Name: ____________________________________________________ Date: _______________
Age: _________ Date of Birth: __________ Gender: Female / Male. Height________Weight__________
Parent/Guardian’s Name: _________________________________________________________________
Address: ______________________________________________________________________________
City: ____________________________________ State: ________________ Zip: ____________________
Telephone (home/cell): ____________________________ (Parent’s work):________________________
Parent’s email address: __________________________________________________________________
How did you hear about this clinic? ________________________________________________________
Has any other friend or family member already been a patient at this clinic?_______________________
Name of doctor’s office/hospital/clinic where your child’s health records are kept:__________________
______________________________________________________________________________________
Reason for referral or presenting problems: _________________________________________________
Would you like to receive our email newsletter for articles, news, events, and discounts? ____________
What method(s) can we use to contact you? cell phone ____ home phone ____ e-mail ____ mail _____
MEDICATIONS
NOW PAST
NOW PAST
NOW PAST
____ ____ Aspirin ____ ____ Decongestants
____ ____ Ibuprofen
____ ____ Tylenol ____ ____ Anti-histamine
____ ____ Antibiotics
____ ____ Other ____________________________ Allergies to medicines: ________________________
MEDICAL HISTORY
____ Chicken pox
____ Scarlet fever
____ Tonsillitis, approx no. of times: _______
____ Measles
____ Pneumonia
____ Ear infections, approx no. of times: ____
____ Mumps
____ Frequent colds
____ Strep throat, approx no. of times: _____
____ Rubella
____ Rheumatic fever
____ Other: _________________________
Has your child ever had any of the following?
WHEN
WHERE
RESULTS
Electroencephalogram (EEG): __________________________________________________________
Psychological evaluations:_____________________________________________________________
Hearing test: ________________________________________________________________________
Speech/language tests: _______________________________________________________________
Injuries/surgeries/hospitalizations (please list): _____________________________________________
IMMUNIZATIONS
____ MMR
____ DPT
____ Chicken pox
Others:___________________
____ Measles
____ Diphtheria
____ Small pox
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
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____ Mumps
____ Rubella
____ Tetanus
____ Polio
Adverse reactions: Y / N
If so, what? _________________
__________________________
____ H. influenza
____ The flu
FAMILY HISTORY
____ Heart disease
____ Hypertension
____ Cancer
____ Mental illness
____ Diabetes
____ Osteoporosis
____ Arthritis
____ Allergies
____ Other ______
____ Birth defects
____ Tuberculosis
____ Asthma
PRENATAL HISTORY
Previous pregnancies by natural mother, miscarriages, or complications? ________________________________
Mother’s age at child’s birth: ______
Mother’s health during pregnancy:
____ Bleeding
____ Nausea
____ Hypertension
____ Diabetes
____ Physical or emotional trauma
____ Illnesses
____ Thyroid problems
____ Cigarettes, alcohol, drug consumption ____ Medications
BIRTH HISTORY
Term: ______ Full____ Premature____ Late Length of labor: _______ Complications:________
Birth city & state: _______________________________________ Birth weight:_____________
Did you child have any of the following problems shortly after birth?
____ Rashes
____ Birth injuries
____ Blue baby
____ Jaundice
____ Seizures
____ Cerebral palsy
____ Colic
____ Fever
____ Birth defects
Other: ______________________________________________________
Child’s sleep patterns (1st year): ________________________________________________
Food intolerances: ___________________________________________________________
Breast fed: Y / N How long: __________ Formula: Y / N Type (milk, soy):_______________
Age began solids: _________ Which foods:________________________________________
Age began: Sitting _______ Crawling _______ Walking _______ Talking ________
SYMPTOMS
____ Hives
____ Nose bleeds
____ Diarrhea
____Frequent colds
____Bleeding
tendency
____ Burning urine
____ Vomiting spells
____ Hearing loss
____Unusual fears
____ Bloody urine
____ Night sweats
____ Easy bruising
_____Wheezing
____ Eczema
____ High fevers
____ Acne
_____Cough
____ Cries easily
____ Jaundice
____ No appetite
____Body/breath odor
_____Sleep problems
____ Bleeding gums
____Sensitive to light
____
Constipation
____ Asthma
____ Heart murmur
____ Chronic rash
____ Nightmares
____Excessive fatigue
____ Nervous
____ Stomach aches
____ Flat feet
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
-2-
____ Hair loss
____ Allergies
____Frequent urination
____ Anemia
____ Dizzy spells
____ Sore throats
____ Joint pains
TYPICAL DIET
Breakfast: _________________________________________________________________
Lunch: ____________________________________________________________________
Dinner: ____________________________________________________________________
Snacks: ___________________________________________________________________
To drink: _________________________________________________________________
THANK YOU. WE LOOK FORWARD TO HELPING YOU
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
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