Pediatric Intake Form

A NOTE TO OUR PATIENTS: Naturopathic and preventative health care are only possible when the doctor has a complete picture of the patient: physically, mentally and emotionally. To help us serve you better, please complete this questionnaire for your child as thoroughly as possible. Thank you!

Name of person filling out the form
NOTE: This is a confidential record of the child’s medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us in writing to do so. Please complete this questionnaire as thoroughly as possible. Thank you!
PrefixFirstLastSuffix
Name of child
PrefixFirstLastSuffix
Date of Birth
Age
Please enter a value between 0 and 19.
Sex
- Male
- Female
Blood Type
Height
cm
Weight
kg
Contacts
Name
FirstLast
Phone
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Relationship to Child
Name
FirstLast
Phone
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Relationship to Child

Other Health Care Providers
Name
FirstLast
Type of Provider
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
Name
FirstLast
Type of provider
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
Name
FirstLast
Type of provider
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
How did you hear about this clinic
What other health care is this child presently receiving?

Family History
Mother's Age
Mother's General Health
If mother is deceased, please list cause of death, and age at death
Father's Age
Father's General Health
If father is deceased, please list cause of death, and age at death
Maternal Grandmother's Age
Maternal Grandmother's General Health
If Maternal Grandmother is deceased, please list cause of death, and age at death
Maternal Grandfather's Age
Maternal Grandfather's General Health
If maternal grandfather is deceased, please list cause of death, and age at death
Paternal Grandmother's Age
Paternal Grandmother's General Health
If paternal grandmother is deceased, please list cause of death, and age at death
Paternal Grandfather's Age
Paternal Grandfather's General Health
If paternal grandfather deceased, please list cause of death, and age at death
Sisters
First Sister's Age
First Sister's General Health
If first sister is deceased, please list cause of death, and age at death
Second Sister's Age
Second Sister's General Health
If second sister is deceased, please list cause of death, and age at death
Third Sister's Age
Third Sister's General Health
If third sister is deceased, please list cause of death, and age at death
Fourth Sister's Age
Fourth Sister's General Health
If fourth sister is deceased, please list cause of death, and age at death
Fifth Sister's Age
Fifth Sister's General Health
If fifth sister is deceased, please list cause of death, and age at death
Brothers
First Brother's Age
First Brother's General Health
If first brother is deceased, please list cause of death, and age at death
Second Brother's Age
Second Brother's General Health
If Second brother is deceased, please list cause of death, and age at death
Third Brother's Age
Third Brother's General Health
If third brother is deceased, please list cause of death, and age at death
Fourth Brother's Age
Fourth Brother's General Health
If fourth brother is deceased, please list cause of death, and age at death
Fifth Brother's Age
Fifth Brother's General Health
If fifth brother is deceased, please list cause of death, and age at death

Online Services

Pediatric Intake Form

Step 1 of 8

Contacts

Other Health Care Providers

Present health concern(s)

Health history

Hospitalizations

Surgeries

Serious illnesses or injury

Immunization history

Medications

Allergies

Family History

Prenatal history

Birth history

Neonatal history

Feeding history

Introduction of solid foods:

General information

Sleeping habits:

Behaviour and emotional history:

Milestone ages