Child Intake Form

advertisement

Dr. Lynette Panych

122 3rd Ave West Cochrane www.cochranenaturopath.ca

(P) 403.932.7775

PATIENT INTAKE FORM - CHILD

NAME: ________________________________________________________________

DATE OF BIRTH: __________ AGE: _______ MALE [ ] FEMALE [ ]

NAME OF PARENTS OR GUARDIANS : ___________________________________

ADDRESS: _____________________________________________________________

______________________________________________ POSTAL CODE: _________

HOME PHONE #: ___________________ WORK PHONE #: ___________________

PLACE OF BIRTH: ______________________________________________________

DAYCARE / SCHOOL ATTENDING: _______________________________________

PHONE #: ___________________________

FAMILY PHYSICIAN: ____________________________________________________

PHONE #: ______________________________

CHIEF HEALTH CONCERNS (IN ORDER OF IMPORTANCE):

1. ____________________________________________________________

2. ____________________________________________________________

3. ____________________________________________________________

4. ____________________________________________________________

5. ____________________________________________________________

SOURCE OF REFERRAL: _________________________________________________

PLEASE STATE WHY YOU HAVE CHOSEN NATUROPATHIC MEDICINE FOR YOUR

CHILD: ____________________________________________________________________________

_____________________________________________________________________________________

HEALTH HISTORY:

HEALTH OF:

MOTHER AT CONCEPTION:

EXC. GOOD FAIR POOR

[ ] [ ] [ ] [ ]

FATHER AT CONCEPTION: [ ] [ ] [ ] [ ]

MOTHER THROUGHOUT PREGNANCY [ ] [ ] [ ] [ ]

CHILD AT BIRTH

DETAILS OF PREGNANCY:

CHILD'S FIRST YEAR OF LIFE

[ ] [ ] [ ] [ ]

[ ] [ ] [ ] [ ]

PRESCRIPTION DRUGS, SUPPLEMENTS, HOMEOPATHIC REMEDIES, VITAMINS, AND OVER

THE COUNTER MEDICATIONS OF MOTHER DURING

PREGNANCY:________________________________________________________________________

___________________________________________________________

DIET DURING PREGNANCY:_____________________________________________

_____________________________________________________________________________________

___________________________________________________________

1

Dr. Lynette Panych

122 3rd Ave West Cochrane www.cochranenaturopath.ca

(P) 403.932.7775

EMOTIONAL STATE OF MOTHER DURING PREGNANCY: ___________________

________________________________________________________________________

WERE ANY OF THE FOLLOWING USED DURING PREGNANCY:

AMOUNT AND FREQUENCY

ALCOHOL

TOBACCO

[ ] ________________________________________________

[ ] ________________________________________________

DRUGS [ ] ________________________________________________

DETAILS OF BIRTH:

NATURAL [ ] C-SECTION [ ] INDUCED [ ] BREECH [ ]

PREMATURE [ ] OVERDUE [ ] EPIDURAL [ ] FORCEPS [ ]

HOSPITAL [ ] HOME BIRTH [ ] MIDWIFE [ ]

NAME OF DELIVERER: ______________________ BIRTH WEIGHT: __________

ANY OTHER PERTINENT INFORMATION REGARDING CHILD'S BIRTH:

_____________________________________________________________________________________

___________________________________________________________

BREASTFED? YES [ ] NO [ ]

IF YES, HOW LONG? ____________________________________________________

FORMULAS OR TYPE OF MILK USED: ____________________________________

FOODS INTRODUCED:

BEFORE 6 MONTHS: ____________________________________________________

6-12 MONTHS: __________________________________________________________

________________________________________________________________________

HAS YOUR CHILD SUFFERED ANY OF THE FOLLOWING:

DATES AND TREATMENT

JAUNDICE

COLIC

INFANT ANEMIA

TONSILLITIS

EAR INFECTIONS

SKIN PROBLEMS OR ECZEMA

WORMS

ALLERGIES

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

RESPIRATORY PROBLEMS

DIGESTIVE PROBLEMS

HYPERACTIVITY

MONONUCLEOSIS

[ ] ____________________________________

[ ] ____________________________________

[ ] ____________________________________

[ ] ____________________________________

CHICKEN POX

MEASLES

[ ] ____________________________________

[ ] ____________________________________

OTHER [ ] ____________________________________

EXTRA INFORMATION: _________________________________________________

________________________________________________________________________

2

Dr. Lynette Panych

122 3rd Ave West Cochrane www.cochranenaturopath.ca

(P) 403.932.7775

HAS YOUR CHILD BEEN VACCINATED? YES [ ] NO [ ]

DID YOUR CHILD SUFFER ANY ADVERSE REACTIONS FROM ANY OF THE

VACCINATIONS? ________________________________________________

_____________________________________________________________________________________

___________________________________________________________

PHYSICAL DEVELOPMENT:

CUT TEETH

AGE

___________

SIT UP

WALK

___________

___________

ROLL OVER

CRAWL

FIRST WORD

AGE

___________

___________

___________

CURRENT HEALTH:

ALLERGIES AND / OR INTOLERANCES : _________________________________

________________________________________________________________________

HAS YOUR CHILD HAD AN ALLERGY SCREENING TEST? __________________

DATE: _______________ PERFORMED BY: _________________________________

RESULTS: ______________________________________________________________

TYPICAL DIET OF YOUR CHILD:

BREAKFAST LUNCH DINNER SNACKS

________________ ________________ ________________ __________________

________________ ________________ ________________ __________________

________________ ________________ ________________ __________________

________________ ________________ ________________ __________________

DO THEY EXPERIENCE ANY SYMPTOMS AFTER EATING CERTAIN FOODS?

_____________________________________________________________________________________

___________________________________________________________

HAS YOUR CHILD EVER TAKEN ANTIBIOTICS ? __________________________

DATE ANTIBIOTIC REASON

_________ _______________

_________ _______________

_________ _______________

_________ _______________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

OTHER MEDICATIONS (INCLUDE OVER THE COUNTER DRUGS, HERBS, HOMEOPATHIC

REMEDIES, VITAMINS, AND PRESCRIPTION DRUGS)

DATE MEDS REASON

_________ _______________

_________ _______________

_________ _______________

_________ _______________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

_________ _______________

_________ _______________

__________________________________________

__________________________________________

3

Dr. Lynette Panych

122 3rd Ave West Cochrane www.cochranenaturopath.ca

(P) 403.932.7775

ADVERSE REACTIONS TO MEDICATIONS? PLEASE DESCRIBE. _____________

_____________________________________________________________________________________

___________________________________________________________

ACCIDENTS, INJURIES, SURGERIES AND HOSPITALIZATIONS:

_____________________________________________________________________________________

___________________________________________________________

HOW WOULD YOU BEST DESCRIBE YOUR CHILD?

INTROVERTED [ ] EXTROVERTED

SHY

PASSIVE

[ ]

[ ]

AGGRESSIVE

ACTIVE

[ ]

[ ]

[ ]

ATHLETIC

LEADER

SERIOUS

EMOTIONAL

[ ]

[ ]

[ ]

[ ]

CREATIVE [ ]

FOLLOWER [ ]

LAID BACK [ ]

PHYSICAL [ ]

HAPPY [ ] SAD [ ]

OTHER ________________________________________________________________

DESCRIBE YOUR CHILD'S PERFORMANCE AT SCHOOL : __________________

________________________________________________________________________

TYPE OF HOME HEATING: _________________________ AGE OF HOME: _____

RUGS [ ] HARDWOOD [ ] LINOLEUM [ ]

DOES ANYONE LIVING IN THE HOUSE SMOKE? _________ AMOUNT: ________

DESCRIBE THE EMOTIONAL CLIMATE OF YOUR HOME:

_____________________________________________________________________________________

_____________

HOBBIES OF CHILD:

_____________________________________________________________________________________

_____________

FAMILY HISTORY (health issues)

Mother:

Father:

Siblings:

Maternal grandparents:

Paternal grandparents:

Please circle any family history of following conditions:

Cancer, Heart Disease, Diabetes, Multiple Sclerosis, Parkinson's, Alzheimer's, Rheumatoid arthritis,

Mental Illness, Asthma, Allergies, Psoriasis, Eczema, Alcoholism, Glaucoma, High Blood Pressure,

Kidney Disease, Thyroid Disease, Inflammatory Bowel Disease

PLEASE LIST CHILDREN IN YOUR FAMILY:

NAME AGE SEX

_____________________________________________________

_____________________________________________________

4

Dr. Lynette Panych

122 3rd Ave West Cochrane www.cochranenaturopath.ca

(P) 403.932.7775

Child REVIEW OF SYSTEMS

Vitality

Low stamina

Fatigue

Depression

Poor sleep

Poor concentration

Poor memory

Anxiety

Bad temper

Easily stressed

Skin

Dryness

Itching

* Please write C for current issues and P for past issues*

Ears

Loss of hearing

High blood pressure

Anemia

Ringing in the ears

Wax build-up

Ear Pain

Ear Infections

Nose

Itching

Loss of Smell

Discharge

Sneezing

Sinusitis

Polyps

Fainting

Fingernails

White spots on nails

Nails won’t grow

Splitting, Peeling,

Cracking

Gastrointestinal

Heartburn

Indigestion

Belching

Nosebleeds Bumps on back of arms

Pimples / Acne

Cracking

Eczema

Psoriasis

Easy bruising

Poor wound healing

Musculoskeletal

Weakness

Stiffness

Aches

Twitching

Cramps

Joint pain

Head

Migraines

Tension Headaches

Head trauma

Eyes

Burning

Dryness

Itching

Double vision

Blurring

Sensitive to light

Failing vision

Conjunctivitis / Styes

Mouth / Lips

Cold sores

Lips cracking

Cankers

Jaw clicks

Jaw pain

Bad breath

Peculiar taste in mouth

Teeth

Cavities

Sensitive to hot / cold

Bleeding gums

Grinding teeth

Respiration

Hay fever

Asthma

Coughing

Bronchitis

Shortness of breath

Frequent sore throats

Frequent colds / cough

Circulation / Blood

Cold hands / feet

Edema (swelling)

Low blood pressure

Flatulence

Bloating after eating

Fatigue after eating

Nausea / vomiting

Constipation

Diarrhea

Alternating diarrhea and constipation

Irritable if late for a meal

Emotional on empty stomach

Wake at night hungry

Excess thirst

Urination

Increased Frequency

Blood in urine

Painful urination

Night urination

Incontinence

Neurological

Seizures / convulsions

Muscle weakness

Numbness / tingling

Memory loss

Involuntary movement

Loss of balance

Speech problems

5

Dr. Lynette Panych

122 3rd Ave West Cochrane www.cochranenaturopath.ca

(P) 403.932.7775

Dr. Lynette Panych, ND

Acknowledgment and Consent For Naturopathic Medicine:

Naturopathic doctors provide primary and complementary health care by focusing on the scientific use of natural therapies to support and stimulate healing processes. Naturopathic doctors use standard medical diagnostic tools (physical exam, fitness testing, health history, laboratory and imaging studies, etc.) Therapies used in naturopathic practice are:

* Botanical Medicine

* Homeopathic Medicine

* Traditional Chinese Medicine/Acupuncture

* Clinical Nutrition

* Lifestyle/Fitness Counseling

*Vitamin Injections

A confidential record will be kept of your health consults and will not be released without your consent or unless directed by law. I permit Dr. Panych, NDto use her discretion in consulting with other professionals (who are also bound by provincial privacy laws) regarding my health in order to provide me with optimal medical care.

(You may look at your file at any time and can request a copy by paying a minimal fee.)

I voluntarily consent to the diagnostic and therapeutic procedures mentioned above.

I understand that there are health risks involved with Naturopathic Medicine services and I hereby release Dr. Lynette Panych, ND from any claims, demands and causes of action arising from my voluntary participation in these services.

I understand that failure to follow naturopathic prescriptions could undermine the expected results. Naturopathic Doctors reserve the right to determine which cases fall outside his/her scope of practice, in which event an appropriate referral will be made.

I allow communication via Email as it saves resources and response times. Dr. Panych, ND makes every attempt to prevent computer / internet criminal activity. I understand the inherent risk involved with computer and internet use and release Dr. Panych, ND from any liability.

All fees for services and supplements are payable at the time of the appointment. There is a fee for completing insurance forms, letter writing, and telephone consultations of greater than 5 minutes. Please give 24 hour notice for appointment cancellations and acknowledge that failure to do so will result in a cancellation fee for the full cost of the appointment booked .

I have read, understood, and acknowledge the above statements. I intend this consent form to cover the entire course of treatment/training. I am free to withdraw my consent and or terminate treatment at any time.

DATE PRINTED NAME

_______________________ _______________________________ _________________

SIGNATURE

2

Download