Center for Holistic Medicine Pediatric Intake Form
Name:
Primary Address (person completing this questionnaire)
Alternate Address:
Emergency Contact:
*It is extremely important that you list the pharmacy’s fax number
*Note: If Discover is your primary card, please provide another card (i.e., MC or Visa) for transactions (i.e., supplement orders, etc.) that we may need to process. Some pharmacies do not accept Discover
If you had a magic wand and could help your child in three ways, what would they be?
Please list current and ongoing problems in order of priority:
Add new row
Diseases/Diagnosis/Conditions (Check appropriate box and provide date of onset)
Check box if yes and provide date.
Check box if yes and provide date
Please attach a copy of all Lab testing that have been performed.
List Family Members:
Resources for emotional support:
Menstrual History
Mother’s Past Pregnancies
Check box if yes and provide description if applicable
Please indicate the approximate age in months for the following milestones: (example: walking 14 months):
Current Medications
Previous Medications: Last 10 years
Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy)
Please list child’s reaction to immunization (Change in stools, crying, seizures, irritability, fever,rash, poor sleep etc.)
Age
0-2 months
2-4 months
4-6 months
6-9 months
9-12 months
12-15 months
15-18 months
18-24 months
Other
List type and amount of activity daily(school, therapies, play etc.):
Please check appropriate box
Mold in bathroom
Damp cellar
Pest extermination - Inside
Pest extermination - Outside
Forced hot air heat
Had water in basement
Mold visible on exterior of house
Heavily wooded or damp surroundings
Mold in cellar, crawl space, or basement
Moldy, musty school/daycare
Tobacco smoke
Well water
Is your child sensitive to any of the following?
Please check all current symptoms occurring or present in the past 6 months.
Rate on a scale of: 5 (very willing) to 1 (not willing).
In order to improve your child’s health, how willing is the patient in:
Rate on a scale of: 5 (very confident) to 1 (not confident at all)
Rate on a scale of: 5 (very supportive) to 1 (very unsupportive)
Rate on a scale of: 5 (very frequent contact) to 1 (very infrequent contact)
It is important to keep an accurate record of your child’s usual food and beverage intake as a part of the treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day
The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps track your child’s progress over time. Rate each of the following symptoms based upon your child’s health profile for the past 30 days. If you are taking after the first time, record your child’s symptoms for the last 48 hours ONLY.
0 = Never or almost never have the symptom
3 = Frequently have it, effect is not severe
1 = Occasionally have it, effect is not severe
4 = Frequently have it, effect is severe
2 = Occasionally have, effect is severe
Key to Questionnaire: Add individual scores and total each group. Add each group scores and give a grand total. Optimal is less than 10 • Mild Toxicity: 10-50 • Moderate Toxicity: 50-100 • Severe Toxicity: over 100.
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