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
*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:
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
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)