ASD Child Intake Form

Center for Holistic Medicine Pediatric Intake Form

Please correct the errors described below.

GENERAL INFORMATION

Name:

Primary Address (person completing this questionnaire)

Alternate Address:

Emergency Contact:

PHARMACY INFORMATION

*It is extremely important that you list the pharmacy’s fax number

PHARMACY INFORMATION

*It is extremely important that you list the pharmacy’s fax number

CREDIT CARD INFORMATION

*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

PRIMARY CARD

SECONDARY CARD

Pediatric Medical Questionnaire

Allergies

Complaints/Concerns

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:

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Diseases/Diagnosis/Conditions (Check appropriate box and provide date of onset)

GASTROINTESTINAL

CARDIOVASCULAR

METABOLIC/ENDOCRINE

CANCER

GENITAL AND URINARY SYSTEMS

MUSCULOSKELETAL/PAIN

INFLAMMATORY/AUTOIMMUNE

RESPIRATORY DISEASES

SKIN DISEASES

NEUROLOGIC/MOOD

PREVIOUS EVALUATIONS

Check box if yes and provide date.

INJURIES

Check box if yes and provide date

SURGERIES

Check box if yes and provide date

Please attach a copy of all Lab testing that have been performed.

HOSPITALIZATIONS

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PSYCHOSOCIAL

STRESS/COPING

SLEEP/REST

ROLES/RELATIONSHIPS

List Family Members:

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Resources for emotional support:

GYNECOLOGIC HISTORY (FOR WOMEN ONLY)

Menstrual History

GI HISTORY

DENTAL HISTORY

PATIENT BIRTH HISTORY

Mother’s Past Pregnancies

Mother’s Pregnancy

Check box if yes and provide description if applicable

PREGNANCY

PERINATAL

BIRTH WEIGHT AND APGAR

EARLY CHILDHOOD ILLNESSES

Months.
Months

DESCRIPTION OF DEVELOPMENTAL PROBLEMS

DEVELOPMENTAL HISTORY

Please indicate the approximate age in months for the following milestones: (example: walking 14 months):

Months
Months
Months
Months
Months
Months
Months
Months
Months
Months

MEDICATIONS

Current Medications

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Previous Medications: Last 10 years

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Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy)

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FAMILY HISTORY

Check family members that apply