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

Bottlefed History

Actvity

List type and amount of activity daily(school, therapies, play etc.):

Envronmental History

Please check appropriate box

Bedding: Synthetic, down, feather, cotton, organic

Type: Crib, Junior bed, Adult bed

Flooring(circle): Carpet wall to wall, Area rug, Wood, Glued down, Synthetic padding, carpet
throughout house.

Is your child sensitive to any of the following?

Some things about your Parents

Mother - Personal

Father - Personal

Symptom Review

Please check all current symptoms occurring or present in the past 6 months.

Strengths

Sleep

Physical

Skin

Digestive

Eating

Behavior

Mood

Sensory

Neuromuscular

Speech

Respiratory

Reproductive

Urinary

Readiness Assessment

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)

3-Day Diet Dairy Instructions

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.

  • Do not change your child’s eating behavior at this time, as the purpose of this food record is to analyze present eating habits.
  • Record information as soon as possible after the food has been consumed.
  • Describe the food or beverage as accurately as possible e.g., milk - what kind? (whole, 2%, nonfat); toast - (whole wheat, white, buttered); chicken - (fried, baked, breaded), coffee – (decaffeinated with sugar and ½ & ½).
  • Record the amount of each food or beverage consumed using standard measurements such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
  • Include any added items. For example: tea with 1 teaspoon honey, potato with 2 teaspoons butter, etc.
  • Record all beverages, including water, coffee, tea, sports drinks, sodas/diet sodas, etc.
  • Include any additional comments about your child’s eating habits on this form (ex. craving sweet, skipped meal and why, when the meal was at a restaurant, etc).
  • Please note all bowel movements and their consistency (regular, loose, firm, etc.)

Diet Diary

MSQ - Medical Symptom/Toxicity Questionnaire

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.

POINTSCALE
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe

2 = Occasionally have, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe

Digestive Tract

Ears

Emotions

Energy/Activity

Eyes

Head

Heart

Joints/Muscles

Lungs

Mind

Mouth/Throat

Nose

Skin

Weight

Other

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

Health Care Provider Team

Primary Doctor:

DAN physician:

Therapist(s):

Specialist:

Naturopath/Homeopath:

Nutritionist:

Other:

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