New Patient Pediatric Intake form (12 and Under)

North Seattle Natural Medicine

617 5th Ave S. Edmonds, WA 98020

Phone: 206-629-5180
Fax: 206-629-5197

Basic Information

Patient's first name

Patient's last name

Age

Date of birth

Preferred gender pronoun(s)

Gender assigned at birth

Female

Male

Parent/Guardian name

Parent/Guardian phone number

Parent/Guardian email

I acknowledge, I will wear my full mouth/nose covering mask at all times in the lobby and Provider's office. If I do not wear the mask fully, the Provider will inform me to leave the office and switch to Telemedicine only.

I consent to detailed voice messages being left on my voicemail for my phone number listed above. This permission may be rescinded at any time. Please contact the clinic if you wish to rescind.

Yes

What is your preferred method of communication?

Phone

Address 1

Address 2

City

State

Zipcode

Describe

Insurance company network/plan name

I acknowledge that it is my responsibility to confirm that my preferred doctor is in network with the patient's specific insurance plan and if the plan will cover visits with said doctor before the first appointment/upon renewing the insurance plan.

Please list the patient's current health concerns (prioritize in order of importance)

Is the patient experiencing any acute pain? If this is a medical emergency, please call 911.

Yes

Please describe

Problem #1

Concern

Date of onset

Describe

Cause

Where is the patient feeling pain/discomfort? (i.e. head, neck, stomach)

Type of pain/discomfort (i.e. aching, numbness, stabbing pain)

Why is it worsening or improving?

Prescription/surgery/treatments tried & the results

Related personal and/or family history

How does problem #1 affect the patient's body/life?

Problem #2

Concern

Date of onset

Describe

Cause

Where is the patient feeling pain/discomfort? (i.e. head, neck, stomach)

Type of pain/discomfort (i.e. aching, numbness, stabbing pain)

Why is it worsening or improving?

Prescription/surgery/treatments tried & the results

Related personal and/or family history

How does problem #2 affect the patient's body/life?

Problem #3

Concern

Date of onset

Describe

Cause

Where is the patient feeling pain/discomfort? (i.e. head, neck, stomach)

Type of pain/discomfort (i.e. aching, numbness, stabbing pain)

Why is it worsening or improving?

Prescription/surgery/treatment tried & the results

Related personal and/or family history

How does problem #3 affect the patient's body/life?

General Information

Have you had the COVID Vaccine?

Yes

If yes, which type and dates

If no, please explain why.

Doctor's name and office (if applicable)

Explain

What are the most significant measures that the patient has taken to improve their state of health?

Medical History

List the prescription and non-prescription medications, vitamins, minerals, and herbs that you are currently taking, (include the dosage of each)

Please specify the patient's preferred pharmacy

Preferred pharmacy's phone number

List any medications that have been prescribed but patient is not taking

List any major illnesses, hospitalizations, surgeries, or serious injuries (include date and brief description)

Height

Weight

Immunizations

Please check if patient has had the following immunizations.

Hep B

Polio

MMR

Hi B

Hep A

DTap

Varicella

PCV

Influenza

Any others?

Any adverse reactions?

Any questions/concerns about vaccines?

Personal Medical History

Please check if patient has had any of the following.

Chicken Pox

Rheumatic Fever

Eczema

Asthma

Mumps

Pneumonia

Frequent Colds/Flus

Allergies

Measles

Rubella

Scarlett Fever

Ear Infections

Family Medical History

Please check if family member has had any of the following.

Asthma

Tuberculosis

Cancer

Mental Illness

Allergies

Autoimmune disease

Heart Disease

High blood pressure

Arthritis

Diabetes

Review of Systems

Is the patient experiencing any of the following? Fever/chills/night sweats, unexpected weight loss, visual disturbances, itching, pain, discharge from the eyes, heart palpitations, chest tightness/pain/shortness of breath, symptoms of asthma, hay fever, lung infections (bronchitis/pneumonia), frequent colds or flu, nausea, gas/bloating, constipation/diarrhea, rashes, eczema, psoriasis, hives, acne, frequent bladder/kidney infections, stiffness/aching in muscles and joints, headaches/migraines, numbness/tingling, easy bruising, tendency for anxiety, depression, irritability, other. Please list.

Over the last two weeks, how often has the patient been bothered by any of the following problems?

Thank you for filling out our New Patient Intake Form! Once you have submitted it you should expect to hear from us within 5 business days. If you have any questions feel free to give us a call. We'll talk to you soon!

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