Naturopathic Pediatric intake form

By filling out this form, I confirm that I have read the information and understand that the form of medical care is based on naturopathic and other supportive principles and practices. I recognize that even the gentlest therapies potentially have their complications in certain physiological conditions or in very young children or those on multiple medications and hence the information provided is complete and inclusive of all health concerns including the possibility of pregnancy; and all medications, including over the counter drugs and supplements. The slight health risks of some naturopathic treatments include, but are not limited to: aggravation of pre-existing symptoms, allergic reaction to supplements or herbs; pain, fainting, bruising, or injury from venipuncture or acupuncture, and muscle strains and sprains.

If you prefer to print out the form and bring in to the office, you can download the form here

Ped Intake Form Age 0-8

Name(Required)
MM slash DD slash YYYY
Sex
Address(Required)
Preferred contact number for reminder/follow up calls:

Emergency Contact

Medical Information

Doctors Address
MM slash DD slash YYYY

Health Information

Most important, Second most important, etc

Medical History

Which of the following has your child had?
Please indicate any immunizations your child has had and the date of immunization (if you prefer, you may submit a copy of the immunization record):
Is there anyone with a significant or chronic disease not mentioned above who is related or is non-related that lives in the home?
Was your child adopted?
If your child was adopted please complete as much information as you can concerning prenatal and birth information.

Prenatal Information

Was the pregnancy planned?
Were any fertility treatments undertaken?
Was this the first pregnancy for the mother?
What, if any, prenatal testing was undertaken (please check all that apply)
Please check off any conditions which occurred during the pregnancy:
Did the mother smoke during the pregnancy?
Did the mother consume alcohol during the pregnancy?
Did the mother participate in any drug use during the pregnancy?
If the mother worked prior to the pregnancy, did she need to take any time off during the pregnancy?

Birth Information

Name of Midwife or Obstetrician
Home (please specify city), Hospital (please specify hospital name and city)
Were any medications taken during the birth/labour?
Were any interventions performed during the birth?
If yes, please check all that apply:
Were there any concerns or complications during the birth?
If yes, please check all that apply:

Feeding History

Was your child breastfed?
Was your child formula fed?

Please list the age at which the following food introductions took place. Also list any reactions (constipation, diarrhea, skin rashes, etc) when these food were introduced.

Please describe your child’s typical daily diet:

Family Life

Social History

How is your child educated?
Does your child attend daycare?

Developmental Milestones

Please list the approximate age that your child achieved the following milestones:

Sleep History:

Where in the home does your child sleep?
Does your child have any difficulty falling asleep?

Environment

Does anyone smoke cigarettes or marijuana in the home?
What type of water is drank in the home

What type of cleaning products are used in the home (please indicate the % used for each)

Does the home have an air filter?

Review of Symptoms

Does your child wear corrective lenses or contacts?