Child Intake Form

While this form is coded as securely as it can be, this form is not on a secured https page. If you would prefer, you may download a copy here and fill it out by hand.

Please fill out every field that applies.

Child's Full Name: *
Child's Birthday:	Year
Child's Sex	Female Male
Child's Address: City: Postal Code:
Caregiver's Name(s): *
Caregiver's Address: If Different from above
Phone Home:*
Emergency Phone:
Siblings-Names & Ages:
Family Doctor/Pediatrician Name and Address

What are your major concerns about your child's health?

What are your other concerns about your child's health?

Have any of the above conditions been diagnosed?	Yes No
If so, by whom?

Medical History
How would you describe your child's general state of health??	Good Fair Poor
Which of the following illnesses has your child had?
Rubella (German Measles)	Never Mild Average Severe
Roscolla	Never Mild Average Severe
Impetigo	Never Mild Average Severe
Measles	Never Mild Average Severe
Scarlet Fever	Never Mild Average Severe
Mononucleosis	Never Mild Average Severe
Chicken Pox	Never Mild Average Severe
Impetigo	Never Mild Average Severe
Ear Infections	Never Mild Average Severe
Mumps	Never Mild Average Severe
Whooping Cough	Never Mild Average Severe
Please list any medications, including over-the-counter, vitamins, homeopathics, herbs, etc. taken in the past:

Please list any present medications, including over-the-counter, vitamins, homeopathics, herbs, etc.

Please list your child's immunizations: Diphtheria/Pertussis/Tetanus, Tetanus Booster, Measles/Mumps/Rubella, Haemophilus Influenza B, Flu, Hepatitis, Polio, Other	Please list all that apply:
What was the date of the Tetanus Booster Shot?
Please indicate if any immunization caused adverse reactions:
How many times has your child had Antibiotics?
For what reason?:
Dental History or cavities:
List all locations of child's scars.

Prenatal Health
How was the health of the mother during pregnancy	Poor Fair Good Excellent Unknown
Mother's Age at Child Birth:
How was the mother's diet during pregnancy?	Poor Fair Good Excellent Unknown
Did the mother receive pre-natal medical care?	Yes No Unknown
Did the mother experience any of the following during pregnancy: Bleeding, High Blood Pressure, Nausea, Vomiting, Diabetes, Thyroid, Physical or Emotional Trauma or Other Symptoms	Please list all that apply:
Explain Other maternal symptoms?
Did the mother use any of the following during pregnancy: Tobacco, Alcohol, recreational drugs, Prescription drugs, Over the Counter Medication, Supplements, Other	Please list all that apply:
Please give details of use of any of the above:
BIRTH HISTORY
Term Length	Full Premature Late
If premature or Late, by how many weeks?

Length of labour

Baby's Weight at Birth

Any complications?

Was the birth: Vaginal, C-Section, Induced, Forceps, Anesthesia Used	Please list all that apply:
Did the baby experience any of the following symptoms after the birth? Jaundice, Rashes, Seizures, Birth Injuries, Birth Defects, Other	Please list all that apply:
If "Other" please explain:

DIET
How was your baby fed? Breast, Milk Based Formula, Soy Based Formula, Other	Please list all that apply:
If "Other" please explain:

If you breast fed, how long did you continue?
What foods were introduced before 6 months? Please list approximate months as well.

Foods 6 - 12 Months.

Did your child ever experience colic?	Yes No
How Severe Was the Colic?	Mild Moderate Severe
Does your child have any food allergies or intolerances? Please List

Do either of the parents have a chronic illness?	Yes No
Please describe parent's chronic illness

Does your child have any dietary restrictions (religious, vegetarian/vegan?)

TYPICAL DAILY FOOD INTAKE
Breakfast.

Lunch.

Dinner.

Snacks.

Beverages-Total-Quantity.

Anything You Would Like to Add
Comment

Child Intake Form

Medical History

Prenatal Health

Anything You Would Like to Add