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 last name

Patient's first name

Age

Date field

Preferred gender pronoun(s)

Gender assigned at birth

Female

Male

Parent/Guardian name

Parent/Guardian phone number

Parent/Guardian email

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 This permission may be rescinded at any time.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

Address 1

Address 2

City

State

Zipcode

Allergies to drugs, food, or other substances

Describe

Which doctor would you prefer the patient to see?

If your preferred doctor is not able to accept new patients at this time, which doctor would be your secondary choice?

Insurance company network/plan name

Have you verified that the patient's insurance will cover your preferred doctor at North Seattle Natural Medicine?

Please note, due to the differences in each patient's insurance plan we rely on you to know your coverage. You can visit our website at https://www.northseattlenaturalmedicine.com/insurance to verify your insurance!

I acknoweldge 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)

Regularity

Status

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)

Regularity

Status

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)

Regularity

Status

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

Has the patient seen a naturopathic doctor before?

Is the patient currently seeing a naturopathic doctor?

Doctor's name and office (if applicable)

Does the patient have a medical doctor?

Doctor's name and office (if applicable)

Does the patient see any other healthcare professional (i.e. acupuncturist, chiropractor, massage therapist, counselor)

Explain

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

Any exposure to tobacco at home?

Are there any guns in the home?

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?

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

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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