Pediatric Intake Form

Please correct the errors described below.

General Information

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:

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

Psychosocial

Stress/Coping

Sleep/Rest

Roles/Relationship

List Family Members:

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 (Click yes if it applies to you and provide description if applicable)

Pregnancy

Perinatal

Birth Weight and APGAR

Early Childhood Illnesses

Developmental History

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

Medications

Current Medications

Previous Medications: Last 10 years

Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy)

Family History

Check family members that apply

Please provide age if still alive

Please provide age if Deceased.

Check family members that apply:

Immunizations:

Please list child’s reaction to immunization (Change in stools, crying, seizures, irritability, fever,
rash, poor sleep etc.)

Age 0-2 Months

Age 2-4 Months

Age 4-6 Months

Age 6-9 Months

Age 9-12 Months

Age 12-15 Months

Age 15-18 Months

Age 18-24 Months

Other

Nutritional History

Breastfeed History