North Bay Naturopathic Clinic

Pediatric Intake Form

Child's Name:
Who is filling out this form (name and relation)?
Email:
How did you hear about our clinic?

Personal Information

Date of Birth:
Age:
Gender:
Height (inches):
Weight (kilograms):
Ethnicity:
Religious practices:

Contacts

Name:
Address:
Phone:
Home:
Work
Other:
Relation to child:
Emergency Contact
Phone:
Home:
Work:
Other health care providers
1. Name:
Occupation:
Phone:
2. Name:
Occupation:
Phone:
3. Name:
Occupation:
Phone:
What are the child’s chief concerns
1.
2.
3.
4.

Prenatal Health

What was mother’s age at childbirth?
Did mother receive prenatal health care?
If yes, what type?
Other:
What was mother’s health like at conception?
What was mother’s health like during pregnancy?
During pregnancy did the mother experience any of the following: NauseaDiabetesVomitingThyroid problemsHigh blood pressurePhysical traumaBleedingEmotional traumaEclampsiaDepression Other:
Did the mother use any of the following during pregnancy:
(list amount, frequency and length of time used)
Tobacco:
Alcohol:
Recreational drugs:
Prescription drugs:
Fertility drugs:
Supplements:
Other:
Was the mother exposed to any of the following during pregnancy? PetsPaintNew carpetingNatural gasCarbon MonoxideNew homeCleaning products
Other:

Birth History

Term length: Full Term
Premature: #weeks:
Late: #weeks:
Length of labour:
Any complications at birth? (I. e. breech, trauma)
Type of birth:
Were any of the following drugs used during labour?
Demerol
Nitrous oxide gas
IV Epidural
Spinal Epidural
Anaesthetic
Antibiotics
Any complications for the child after birth?
Low birth weight
Jaundice
Respiratory difficulties
Low APGAR score
Rashes
Seizures
Birth injuries
Birth defects
Other:

Nutrition

Was child breast fed?
How long?
Any problems with weaning?
Was child formula fed?
What kind?
What foods were introduced
Before 6 months:
Any reactions:
Between 6-12 months:
Any reactions:
When where the following foods introduced (approximate age):
Milk
Wheat
Soy
Citrus
Sweets
Who prepares the child’s food?
Describe a typical day’s diet:
Breakfast:
Lunch:
Dinner:
Snacks:
Fluids (quantity):
Does the child have any of the following?
Food intolerances:
Food Cravings:
Aversions to food:

Review of Symptoms

Indicate any of the following which currently apply or have applied in the past to the child:
General feverchillsfatigueweaknessmalaise
Other:
Skin dryness/moistnessrashesmole/birthmarksacne, boilslesionseczemahivesitchinghot/cold
Other:
Head headachehead injurydizzinessrashesdrynessitchy
Other:
Eyes impaired visionglasses/contactspaindischargerednessitchingtearing or dryness
Other:
Ears impaired hearingearacheitchingdischarge
ear infections (how many? )
Other:
Nose and Sinuses frequent colds (how many per year? )
nose bleedsstuffinessitchingdischargesinus problems
Other:
Mouth and Throat frequent sore throatsore tongue/mouthgum problemshoarsenessteethingdroolinglesions, loss of taste
dental cavities (how many? )
Other:
Neck lumpsswollen glandsgoitrepain or stiffness
Other:
Respiratory coughspitting up bloodwheezingasthmabronchitispneumoniapleurisyemphysemapain on breathingdifficulty breathingshortness of breathTuberculosisTuberculin test
last chest x-ray (date):
Other:
Cardiovascular murmursrheumatic feverchest paindifficult feedingsweatingpalpitationscyanosispast ECG
other heart tests:
Other:
GI trouble swallowingchange in thirst or appetitefood allergydiarrhoeaconstipationnausea vomitingvomiting bloodbloatingblack tarry stoolbelchingpassing gasindigestionrectal bleedingjaundice (yellow skin)haemorrhoidsabdominal painhernias
number of bowel movements/day,
is this a change
color of stool
is this a change
Other:
GU rashrednesspain on urinationdischargeincreased frequencyfrequency at nightfrequent infectionsinability to hold urineurgencyhesitancyblood in urine
Other:
Musculoskeletal joint painjoint stiffnessjoint swellingarthritisweaknesssprains/strainsbroken bonesmuscle spasms or crampsbackache
Other:
Peripheral Vascular leg paincold hands/feetleg crampsextremity numbnessswelling or ulcers
Other:
Neurologic tremorirritabilityseizures/convulsionsfaintingparalysismuscle weaknessnumbness or tinglingloss of memoryinvoluntary movementloss of balancespeech problemsdifficulty concentrating
Other:
Endocrine heat or cold intolerancethyroid troubleexcessive thirsthungerincrease in urinationsweatingdiabeteshypoglycaemiahormone therapy
Other:
Blood/Lymphatic anaemiaeasy bleedingeasy bruisingpast transfusionsenlarged lymph nodes
Other:
Emotional depressionmood swingsanxietynervousnesstensionfears and phobiasalcohol abusedrug abuseinsomniaemotional traumaphysical trauma
Other:
Sleep trouble falling asleeptrouble staying asleeprecurrent dreams/nightmaressleepwalknight terrorsbed wetting
Other:

Medical History

How would you describe the child’s general health status:
Please indicate if your child has had any of the following with approximate dates:
Serious illness:
Hospitalizations:
Surgery:
Injury:
Has your child been vaccinated for any of the following (provide dates):
DPT (diphtheria, pertussis, tetanus) Date:
“Flu” Date:
Polio Date:
Hep B Date:
MMR (measles, mumps, rubella) Date:
Hep A Date:
Haemophilus influenza B Date:
Tetanus booster Date:
Has your child had any adverse reactions to any vaccination?
Has your child had any of the following (provide dates):
Rubella Date:
Measles Date:
Impetigo Date:
Roseola Date:
Scarlet fever Date:
Mononucleosis Date:
Chicken pox Date:
Whooping cough Date:
Ear infections Date:
Mumps Date:
Strep throat Date:
Please list all current medications:
Please list all current supplements:
Please list past prescription medications:
How many times has your child used antibiotics?
Please list any allergies
Food:
Drugs:
Environmental:
Do you use an Epi-pen?
Do you have a medical alert bracelet?
Did your child ever have colic? How severe?

Family History

Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
Mother
Father
Sibling
Sibling
Other
Other
  I don't know my medical history

Environmental History

  Is this child in daycare?
  Is this child in homecare?
  Is this child in school? Grade:
What types of physical activities does this child participate in?
How often?
What are the child’s extracurricular activities?
How much time does the child spend watching television and/or playing on computers/video games? Hours per day/week?
Does anyone in the child’s home smoke?
Are there any animals in the child’s home?
How is the child’s home heated/cooled?
Are there any other substances that you believe your child is being exposed to on a regular basis?
How is the child’s temperament?
Does the child have mood swings? How often?
How is the child’s performance at school?
Has the child ever been diagnosed with a learning disability?
Does the child have any fears or anxieties?
How would you rate the stress level in your household on a scale of 1-10, 10 being the most stressful:
Any other concerns or considerations you would like the Naturopath to know about: