Pediatric Intake Form

General Information

First Name:

Middle Name:

Last Name:

Preferred Name:

Date:

Age:

Gender:

Male Female

Ethnic Background:

African European Native American Mediterannean Asian Ashkenazi Middle Eastern Other

Please Specify:

Mother's Name:

Occupation:

Father's Name:

Occupation:

Primary Address (person completing this questionnaire):

Alternate Address:

Home Phone 1:

Home Phone 2:

Parent's Work Phone:

Parent's Cell Phone:

Fax:

Email:

Emergency Contact

Name:

Phone:

Address:

Referred By:

Website Media Friend or Family Member Other(If other please specify)

Pharmacy Information

Primary Pharmacy:

Phone:

Address:

Email:

Fax:

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

Pharmacy Information

Compounding/Supplement Pharmacy:

Phone:

Address:

Email:

Fax:

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

Credit Card Information

Preferred Method of Payment (please circle one):

Cash

Check

Credit Card

Credit Card Type (please circle one):

Visa

Mastercard

Discover

*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

Name on Card:

Card Type:

Visa

MasterCard

Discover

Account Number:

Expiration Date:

CVV #:

Secondary Card

Name on Card:

Card Type:

Visa

MasterCard

Discover

Account Number:

Expiration Date:

CVV #:

Pediatric Medical Questionnaire

What diagnoses has your child been given and at what age?

Who gave you that diagnosis?

Describe your child to me and tell his or her story being as detailed as possible:

Allergies

Medication/Supplement/Food/Environment:

Reaction:

Complaints/Concerns

What do you hope to achieve in your visit with us?

If you had a magic wand and could help your child in three ways, what would they be?

When was the last time you felt your child was well?

Did something trigger your child’s change in health?

Is there anything that makes your child feel worse?

Is there anything that makes your child feel better?

Please list current and ongoing problems in order of priority:

Describe Problem:

Please Select One:

Mild Moderate Severe

Describe Problem:

Please Select One:

Mild Moderate Severe

Describe Problem:

Please Select One:

Mild Moderate Severe

Describe Problem:

Please Select One:

Mild Moderate Severe

Describe Problem:

Please Select One:

Mild Moderate Severe

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

Gastrointestinal

Irritable Bowel Syndrome

Past Current

Date:

Inflammatory Bowel Disease

Past Current

Date:

Crohn’s

Past Current

Date:

Ulcerative Colitis

Past Current

Date:

Gastritis or Peptic Ulcer Disease

Past Current

Date field

GERD (reflux)

Past Current

Date:

Celiac Disease

Past Current

Date:

Other

Past Current

Date:

Cardiovascular

Heart Disease

Past Current

Date:

Elevated Cholesterol

Past Current

Date:

Hypertension (high blood pressure)

Past Current

Date:

Rheumatic Fever

Past Current

Date:

Mitral Valve Prolapse

Past Current

Date:

Other

Past Current

Date:

Metabolic/Endocrine

Type 1 Diabetes

Past Current

Date:

Type 2 Diabetes

Past Current

Date:

Hypoglycemia

Past Current

Date:

Metabolic Syndrome (Insulin Resistance or Pre-Diabetes)

Past Current

Date:

Hypothyroidism (low thyroid)

Past Current

Date:

Hyperthyroidism (overactive thyroid)

Past Current

Date:

Endocrine Problems

Past Current

Date:

Polycystic Ovarian Syndrome (PCOS)

Past Current

Date:

Weight Gain

Past Current

Date:

Weight Loss

Past Current

Date:

Frequent Weight Fluctuations

Past Current

Date:

Bulimia

Past Current

Date:

Anorexia

Past Current

Date:

Binge Eating Disorder

Past Current

Date:

Night Eating Syndrome

Past Current

Date:

Other

Past Current

Date:

Cancer

Please Select One:

Past Current

Date:

Genital and Urinary Systems

Kidney Stones

Past Current

Date:

Urinary Tract Infections

Past Current

Date:

Yeast Infections

Past Current

Date:

Other

Past Current

Date:

Musculoskeletal/Pain

Arthritis

Past Current

Date:

Fibromyalgia

Past Current

Date:

Chronic Pain

Past Current

Date:

Other

Past Current

Date:

Inflammatory/AutoImmune

Chronic Fatigue Syndrome

Past Current

Date:

Autoimmune Disease

Past Immune

Date:

Rheumatoid Arthritis

Past Current

Date:

Lupus SLE

Past Current

Date:

Immune Deficiency Disease

Past Current

Date:

Severe Infectious Disease

Past Current

Date:

Poor Immune Function (frequent infections)

Past Current

Date:

Food Allergies

Past Current

Date:

Environmental Allergies

Past Current

Date:

Multiple Chemical Sensitivities

Past Current

Date:

Latex Allergy

Past Current

Date:

Other

Past Current

Date:

Respiratory Diseases

Frequent Ear Infections

Past Current

Date:

Frequent Upper Respiratory Infections

Past Current

Date:

Asthma

Past Current

Date:

Chronic Sinusitis

Past Current

Date:

Bronchitis

Past Current

Date:

Sleep Apnea

Past Current

Date:

Sleep Apnea

Past Current

Date:

Skin Diseases

Eczema

Past Current

Date:

Psoriasis

Past Current

Date:

Acne

Past Current

Date:

Other

Past Current

Date:

Neurologic/Mood

Depression

Past Current

Date:

Anxiety

Past Current

Date:

Bipolar Disorder

Past Current

Date:

Schizophrenia

Past Current

Date:

Headaches

Past Current

Date:

Migraines

Past Current

Date:

ADD/ADHD

Past Current

Date:

Sensory Integrative Disorder

Past Current

Date:

Autism

Past Current

Date:

Mild Cognitive Impairment

Past Current

Date:

Multiple Sclerosis

Past Current

Date:

Seizures

Past Current

Date:

Previous Evaluations

Check box if yes and provide date.

Full Physical Exam

Past Current

Date:

Psychological Evaluations

Past Current

Date:

Speech and Language Evaluations

Past Current

Date:

Genetic Evaluation

Past Current

Date:

Neurological Evaluations

Past Current

Date:

Gastroenterology Evaluations

Past Current

Date:

Celiac/Gluten testing

Past Current

Date:

Allergy Evaluation

Past Current

Date:

Nutritional Evaluation

Past Current

Date:

Auditory Evaluation

Past Current

Date:

Vision Evaluation

Past Current

Date:

Osteopathic

Past Current

Date:

Acupuncture

Past Current

Date:

Physical Therapy

Past Current

Date:

Occupational Therapy

Past Current

Date:

Sensory Integration Therapy

Past Current

Date:

Speech Classes

Past Current

Date:

Sign Language

Past Current

Date:

Homeopathic

Past Current

Date:

Naturopathic

Past Current

Date

Craniosacral

Past Current

Date:

Chiropractic

Past Current

Date:

MRI

Past Current

Date:

CT Scan

Past Current

Date:

Upper Endoscopy

Past Current

Date:

Upper GI Series

Past Current

Date:

Ultrasound

Past Current

Date:

Injuries

Check box if yes and provide date.

Back injury

Past Current

Date:

Neck Injury

Past Current

Date:

Head Injury

Past Current

Date:

Broken Bones

Past Current

Date:

Other

Past Current

Date:

Surgeries

Check box if yes and provide date.

Appendectomy

Past Current

Date:

Circumcision

Past Current

Date:

Hernia

Past Current

Date:

Tonsils/Adenoids

Past Current

Date:

Dental Surgery

Past Current

Date:

Tubes in Ears

Past Current

Date:

Other

Past Current

Date:

BLOOD TYPE

A B AB O RH+ Unknown

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

Hospitalizations

None

Date:

Reason:

Date:

Reason:

Date:

Reason:

Date:

Reason:

Psychosocial

Has your child experienced any major life changes that may have impacted his/her health?

Yes No

Have your child ever experienced any major losses?

Stress/Coping

Have you ever sought counseling for your child?

Yes No

Is your child or family currently in therapy?

Yes No

Describe:

Does your child have a favorite toy or object?

Yes No

Describe:

Check all that apply:

Yoga

Meditation

Imagery

Breathing

Tai Chi

Prayer

Other:

Has your child ever been abused, a victim of a crime, or experienced a significant trauma?

Yes No

Sleep/Rest

Average number of hours your child sleeps per night:

Greater than 12 10-12 8-10 Less than 8

Does your child have trouble falling asleep or wakes up frequently?

Does your child feel rested upon awakening?

Yes No

Does your child snore?

Yes No

Roles/Relationship

List Family Members:

Family Member and Relationship:

Age:

Gender:

Family Member and Relationship:

Age:

Gender:

Family Member and Relationship:

Age:

Gender

Family Member and Relationship:

Age:

Gender:

Who are the main people who care for your child?

Resources for emotional support:

Check all that apply:

Spouse

Family

Friends

Religious/Spiritual

Pets

Other:

Gynecologic History (For Women Only)

Menstrual History

Age at first period:

Menses Frequency:

Length:

Pain

Yes No

Clotting:

Yes No

Has your period ever skipped?

For how long?

Last Menstrual Period:

Use of hormonal contraception such as:

Birth Control Pills

Patch

Nuva Ring

How long?

GI History

Has your child traveled to foreign countries?

Yes No

Where?

Wilderness Camping?

Yes No

Where?

Ever had severe:

Gastroentiritis Diarrhea

Dental History

Check all that apply:

Silver Mercury Fillings

Gold Fillings

Root Canals

Implants

Tooth Pain

Bleeding Gums

Gingivitis

Problems with Chewing

How many Silver Fillings you already have?

Do you floss regularly?

Yes No

Patient Birth History

Mother’s Past Pregnancies

Number of: Pregnancies:

Live Births:

Miscarriages:

Mother’s Pregnancy (Click yes if it applies to you and provide description if applicable)

Difficulty getting pregnant (more than 6 months):

Yes No

Description:

Infertility drugs used Specify:

Yes No

Description:

In vitro fertilization:

Yes No

Description:

Drink alcohol:

Yes No

Description:

Drink coffee:

Yes No

Description:

Smoke tobacco:

Yes No

Description:

Take Progesterone:

Yes No

Description:

Take prenatal vitamins:

Yes No

Description:

Take antibiotics:

Yes No

Description:

Taking Antibiotics during Labor?

Yes No

Discription:

Take other drugs Specify:

Yes No

Description:

Excessive vomiting, nausea (more than 3 weeks)

Yes No

Description:

Have a viral infection:

Yes No

Description:

Have a yeast infection:

Yes No

Description:

Have amalgam fillings put in teeth:

Yes No

Description:

Have amalgam fillings removed from teeth:

Yes No

Description:

Number of fillings in teeth when pregnant?

Yes No

Description:

Have bleeding (which months?)

Yes No

Description:

Have birth problems:

Yes No

Description:

Group B strep infection

Yes No

Description:

Have c-section because of

Yes No

Description:

Use induction for labor (such as Pitocin)

Yes No

Description:

Have anesthesia -what was used?

Yes No

Description:

Use oxygen during labor

Yes No

Description:

Have an x-ray:

Yes No

Description:

Have Rhogam, if so how many shots:

Yes No

Description:

How many when pregnant?

Yes No

Description:

Gestational Diabetes:

Yes No

Description:

High blood pressure (pre-eclampsia)

Yes No

Description:

High blood pressure/toxemia

Yes No

Description:

Have chemical exposure:

Yes No

Description:

Father have chemical exposure:

Yes No

Description:

Move to a newly built house:

Yes No

Description:

House painted indoors:

Yes No

Description:

House painted outdoors:

Yes No

Description:

House exterminated for insects:

Yes No

Description:

Pregnancy

Total weight gain during pregnancy: (In pounds)

Total weight loss during pregnancy: (In pounds)

Please describe diet during pregnancy:

Please describe labor:

Perinatal

Very active before birth?

Yes No

Hospital/Birthing Center?

Yes No

Needed Newborn Special Care?

Yes No

Appeared healthy?

Yes No

Easily consoled during first month?

Yes No

Antibiotics first month?

Yes No

Experienced no complications first month of life?

Yes No

Birth Weight and APGAR

Weight at birth: (In pounds)

Apgar score at one minute:

Apgar score at 5 mins:

Early Childhood Illnesses

Number of earaches in the first two years:

Number of other infections in the first two years:

Number of courses of prophylactic antibiotics in first 2 years of life:

First antibiotic at (Months)

First illness at (Months)

Developmental History

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

Sitting Up

Never

Dry at night

Never

Crawl

Never

First words (mama, dada)

Never

Pulled to stand

Never

Spoke clearly

Never

Potty trained

Never

Lost language

Never

Walked alone

Never

Lost eye contact

Never

Medications

Current Medications

Medication

Dose

Frequency

Start Date

Reasons for Use

Medication

Dose

Frequency

Start Date

Reason for Use

Medication

Dose

Frequency

Start Date

Reason for Use

Previous Medications: Last 10 years

Medication

Dose

Frequency

Start Date

Reason for Use

Medication

Dose

Frequency

Start Date

Reason for Use

Medication

Dose

Frequency

Start Date

Reason of Use

Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy)

Supplication and Brand

Dose

Frequency

Start Date

Reason for Use

Supplication and Brand

Dose

Frequency

Start Date

Reason for Use

Supplication and Brand

Dose

Frequency

Start Date

Reason for Use

Have your medications or supplements ever caused you unusual side effects or problems?

Yes No

Describe:

Have you had prolonged or regular use of Tylenol?

Yes No

Have you had prolonged or regular use of Acid Blocking Drugs (Tagamet, Zantac, Prilosec, etc.)

Yes No

Frequent antibiotics > 3 times/year

Yes No

Long term antibiotics

Yes No

Use of steroids (prednisone, nasal allergy inhalers) in the past

Yes No

Other medications/supplements or side effects/ comments or other information you would like to discuss:

Family History

Check family members that apply

Please provide age if still alive

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Please provide age if Deceased.

Mother

Father

Brother(s)

SIster(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Check family members that apply:

Cancers

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Colon Cancer

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Breast or Ovarian Cancer

Mother

Fahter

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Obesity

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Diabetes

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Stroke

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Inflammatory Arthritis (rheumatoid, Psoriatic, Ankylosing Sondylitis)

Mother

Father

Brother(s)

Sisters(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Inflammatory Bowel Disease

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Multiple Sclerosis

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Auto Immune Disease (such as Lupus)

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Irritable Bowel Syndrome

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Celiac Disease (Wheat Sensitivity)

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Asthma

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Eczema / Psoriasis

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Food Allergies, Sensitivities or Intolerances

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Environmental Sensitivities

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Dementia

Mother

Father

Brother(s)

SIster(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Parkinson’s

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

ALS or other Motor Neuron Diseases

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Genetic Disorders

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Substance Abuse (such as alcoholism)

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Psychiatric Disorders

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Depression

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Schizophrenia

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

ADHD

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Autism

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Bipolar Disease

Mother

Father

Brother(s)

Sister(s)

Children

Maternal Grandfather

Paternal Grandmother

Aunts

Uncles

Immunizations:

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

Age 0-2 Months

Vaccinations Given

Response or observation

Age 2-4 Months

Vaccinations Given

Response or observation

Age 4-6 Months

Vaccinations Given

Response or observation

Age 6-9 Months

Vaccinations Given

Response or observation

Age 9-12 Months

Vaccinations Given

Response or observation

Age 12-15 Months

Vaccinations Given

Response or observation

Age 15-18 Months

Vaccinations Given

Response or observation

Age 18-24 Months

Vaccinations Given

Response or observation

Other

Vaccinations Given

Response or observation

Do you have any other questions or concerns regarding immunizations?

Any past or current exposure to environmental mold?

Any history of past or current tick exposure or bite, including finding a tick crawling on your skin?

Nutritional History

Has your child ever had a nutrition consultation?

Yes No

Have you made any changes in your child’s diet because of health problems?

Yes No

Describe

Does your child follow a special diet or nutritional program?

Yes No

Please enlist below the that you're allergic to:

Height (feet/inches):

Current Weight:

Height/Weight Fluctuations

Yes No

Does your child avoid any particular foods?

Yes No

If yes, types and reason:

If your child could eat only a few foods daily, what would they be?

Who does the shopping in your household?

Who does the cooking in your household?

How many meals does your child eat out per week?

0-1 1-3 3-5 >5 meals per week

Breastfeed History

Breastfeed

Yes No

How long?

Problems latching on?

Yes No

Sucking quality?

Very Good Good Poor

Exclusively breastfed for how many months?

Bottlefed History

Bottle fed?

Yes No

Type of formula:

Soy Cow's Milk Low Allergy

Introduction of cow’s milk at what month?

Introduction of solid foods at what month?

First foods introduced at what month?

Introduction of wheat or other grain at what month?

Choke/Gas/Vomit on milk?

Yes No

Refused to chew solids?

Yes No

List mother’s known food allergies or sensitivities:

Please describe any other eating concerns that you have regarding your child:

Actvity

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

Type

Amount Daily

Type

Amount Daily

Type

Amount Daily

How much time does your child spend watching tv?

How much time does your child spend on the computer or playing video games?

Envronmental History

Please check appropriate box

Mold in bathroom:

Past

Current

Pest extermination - Inside

Past

Current

Damp cellar

Past

Current

Pest extermination - Outside

Past

Current

Forced hot air heat

Past

Current

Mold visible on exterior of house

Past

Current

Had water in basement

Past

Current

Heavily wooded or damp surroundings

Past

Current

Mold in cellar, crawl space, or basement

Past

Current

Tobacco smoke

Past

Current

Moldy, musty school/daycare

Past

Current

Well water

Past

Current

Bedding: Synthetic, down, feather, cotton, organic

Mattress cover:

Yes No

Type: Crib, Junior bed, Adult bed

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

Other items in room: Describe furniture, toys, stuffed animals, etc

Is your child sensitive to any of the following?

Perfumes/Cosmetics

Mold

Cleaning products

Pollens/Grasses

Soaps

Animals

Gasoline

Paint

Detergents

Dust

Other:

Some things about your Parents

When were your parents married:

If Separated, when:

If Divorced, when:

If Remarried, when:

Custody Arrangements:

Mother - Personal

Father - Personal

Age at your birth:

Education:

Ethnicity:

Blood type:

Symptom Review

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

Pediatric Intake Form

General Information

Emergency Contact

Pharmacy Information

Pharmacy Information

Credit Card Information

Primary Card

Secondary Card

Pediatric Medical Questionnaire

Allergies

Complaints/Concerns

Gastrointestinal

Cardiovascular

Metabolic/Endocrine

Cancer

Genital and Urinary Systems

Musculoskeletal/Pain

Inflammatory/AutoImmune

Respiratory Diseases

Skin Diseases

Neurologic/Mood

Previous Evaluations

Injuries

Surgeries

Hospitalizations

Psychosocial

Stress/Coping

Sleep/Rest

Roles/Relationship

Gynecologic History (For Women Only)

GI History

Dental History

Patient Birth History

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

Medications

Family History

Immunizations:

Nutritional History

Breastfeed History

Bottlefed History

Actvity

Envronmental History

Some things about your Parents

Mother - Personal

Father - Personal

Symptom Review

Strengths

Sleep

Physical