Intake Form Child / Youth

Maggie Savage RHN Pediatric Intake Form

To be used for children 12 years of age or under, and in conjunction with all other forms.

  • Personal Information

    0
  • 1
  • Date*
    2
  • Child's Name*
    3
  • Age at time of initial consult*
    4
  • Date of Birth*
    5
  • Sex*
    Male
    Female
    6
  • Please list any supplements that your child is currently taking:

    Symptoms: Mark C for current and P for past symptom

    7
  • 8
  • Abdominal pain*
    C
    P
    9
  • Acid reflux*
    C
    P
    10
  • Anemia*
    C
    P
    11
  • Bad breath*
    C
    P
    12
  • Bed wetting*
    C
    P
    13
  • Bleeding gums*
    C
    P
    14
  • Body odour*
    C
    P
    15
  • Blood in urine*
    C
    P
    16
  • Canker sores*
    C
    P
    17
  • Changes in appetite*
    C
    P
    18
  • Congestion*
    C
    P
    19
  • Constipation*
    C
    P
    20
  • Cough*
    C
    P
    21
  • Cries easily*
    C
    P
    22
  • Diarrhea*
    C
    P
    23
  • Dizzy spells*
    C
    P
    24
  • Dry skin*
    C
    P
    25
  • Eczema*
    C
    P
    26
  • Excessive fatigue*
    C
    P
    27
  • Excessive perspiration*
    C
    P
    28
  • Flat feet*
    C
    P
    29
  • Frequent headaches*
    C
    P
    30
  • Gas*
    C
    P
    31
  • Hearing loss*
    C
    P
    32
  • Heart murmur*
    C
    P
    33
  • High fevers*
    C
    P
    34
  • Hives*
    C
    P
    35
  • Hyperactivity*
    C
    P
    36
  • Itchy anus*
    C
    P
    37
  • Itchy nose (or picks nose)*
    C
    P
    38
  • Itchy vagina*
    C
    P
    39
  • Jaundice*
    C
    P
    40
  • Jaundice*
    C
    P
    41
  • Joint pains*
    C
    P
    42
  • Migraines*
    C
    P
    43
  • Motion sickness*
    C
    P
    44
  • Nervousness*
    C
    P
    45
  • Nightmares*
    C
    P
    46
  • Night sweats*
    C
    P
    47
  • No appetite*
    C
    P
    48
  • Nosebleeds*
    C
    P
    49
  • Painful urination*
    C
    P
    50
  • Parasites*
    C
    P
    51
  • Psoriasis*
    C
    P
    52
  • Rash*
    C
    P
    53
  • Sensitive to light*
    C
    P
    54
  • Sleep problems*
    C
    P
    55
  • Stomach aches*
    C
    P
    56
  • Sore throat*
    C
    P
    57
  • Teeth grinding*
    C
    P
    58
  • Talks in sleep*
    C
    P
    59
  • Weight gain*
    C
    P
    60
  • Weight loss*
    C
    P
    61
  • Wheezing*
    C
    P
    62
  • Vomiting Spells*
    C
    P
    63
  • Medical History

    64
  • 65
  • Medical History*
    ADD/ADHD
    Allergies (environmental)
    Allergies (food)
    Asthma
    Autism
    Bronchitis
    Chicken Pox
    Croup
    Dental Problems
    Developmental Problems
    Ear infections
    Frequent colds
    Impaired speech
    Measles
    Meningitis
    Mumps
    Neural Tube Defect
    Pneumonia
    Rubella
    Rheumatic fever
    Scarlet Fever
    Tonsilitis
    Whooping cough
    66
  • Other Specify*
    67
  • Medications

    Indicate duration as well

    68
  • 69
  • Medications*
    Antacids
    Antibiotics
    Antidepressants
    Anti-Histamine
    Aspirin
    Clondine
    Declectin
    Decongestant
    Dextroamphetamine
    Epilepsy medication
    Ibuprofen
    Inhaled Steroids
    Ritalin
    Oral Steroids
    Pemoline (Cylert)
    Tylenol
    70
  • Are you aware of any allergies to medications?*
    71
  • Immunizations?*
    72
  • Has your child been immunized?*
    73
  • Were there any reactions to immunization(s)? If so, at what age?*
    74
  • Infant History

    75
  • 76
  • Delivery*
    Full Term
    Premature
    Overdue
    Vaginal
    C-Section
    77
  • Complications?*
    78
  • Feeding

    79
  • 80
  • Breast Fed*
    81
  • Until what age*
    82
  • Formula Fed*
    83
  • When was formula started*
    84
  • When were solid foods introduced?*
    85
  • Did you baby have any of the following?*
    Jaundice
    Colic
    Diarrhea
    Constipation
    Thrush
    86
  • On a typical day, please outline what your child would eat/drink

    87
  • 88
  • Breakfast:*
    89
  • Lunch*
    90
  • Dinner*
    91
  • Snacks*
    92
  • Beverages*
    93
  • How much water does your child consume daily?*
    94
  • What are their favourite foods?*
    95
  • Does your child experience any symptoms after meals?*
    96
  • What percentage of your meals are home-cooked?*
    97
  • Client Statement

    98
  • 99
  • Client Statement*
    I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposed of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.
    100
  • Name of parent / guardian*
    101
  • Address*
    102
  • City*
    103
  • Province*
    104
  • Postal Code*
    105
  • Telephone*
    106
  • Email*
    107
  • Signature*
    108
  • 109
  • 110