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: