Pediatric intake form

PEDIATRIC INTAKE FORM
Last name:________________________ First name and initial: ___________________ Parent(s)/Guardian(s): ____________________________________________________ Address: ___________________________________ City: __________________ Province: _________________ Postal Code: ____-____ Telephone: (___) ___-____ Date of birth: yyyy/mm/dd Height: _________________________ Weight: ____________________
Emergency contact: ________________________ Relationship: __________________
Emergency contact phone: (___) ___-____
Name of present MD: _________________________________Phone (___) ____-_____
Address of present MD: __________________________________________________
Chief complaints:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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Date of onset: yyyy/mm/dd
Onset was: sudden / gradual / associated with an event: _________________________
Maternal Health and Birth History:
Term: premature / full / late
Location: hospital birthing centre home Delivery: vaginal / C-section / breech / forceps APGAR at birth: _____ APGAR at 5 minutes: _____ Birth weight: _____ Problems patient had at birth: breathing other:_______________________________________________ Was the infant alert and responsive within 12 hours of delivery? cord around neck respiratory depression other: ________________________________________________________________ Item(s) applied to patient at birth: medication other: ________________________________________________________________ Maternal condition: # pregnancies: _____ maternal age at patient’s birth: _____ paternal age at conception: _______ Maternal complications: hypertension other: ________________________________________________________________ Maternal health during pregnancy: STDs (herpes/chlamydia/syphilis/trichomonas) Exercise habits during pregnancy: __________________________________________
Stresses during pregnancy (physical/emotional): _______________________________
______________________________________________________________________
Cravings during pregnancy: ________________________________________________
Maternal medications during pregnancy:
Prescription: ____________________________________________________________
Over the counter: ________________________________________________________
Nutritional supplements: __________________________________________________
Childhood Medical Health of Patient:
Past Childhood Illnesses:
asthma
thrush (fungal infection in the mouth from a Candida infection)
Vaccination:
hepatitis B
varivax (chicken pox vaccine)
Any reactions to the vaccines, and if so, what kind? _____________________________
______________________________________________________________________
Growth and development:
At what age did the patient:
respond to sound _______________________ follow on object ___________________
hold head up __________________________ vocalize _________________________
sit alone ______________________________ teethe __________________________
crawl _________________________________ walk ___________________________
Do sleeping patterns seem normal to you? Y / N
Explain: _______________________________________________________________
Feeding History:
Was baby breast fed? Y / N
Introduction of cow’s milk at age ______ Type of solid foods introduced ______________________________________________ Age and type of commercial baby food introduced ______________________________ Any intolerances? Y / N explain: ________________________________________ Any cravings? __________________________________________________________ Is the child a picky eater? Y / N explain: __________________________________
Childhood Drug History:
Any antibiotics? Y / N
total number of courses of antibiotics: ________________ Other medications? Y / N 1-Medication: ______________ for: _____________________________________ Length of time on drug:___________________________________________________ Reactions to drug? ______________________________________________________ 2-Medication: ______________ for: _____________________________________ Length of time on drug:___________________________________________________
Reactions to drug? ______________________________________________________
Supplements: _________________________________________________________
Past hospitalizations: ____________________________________________________
_____________________________________________________________________
Past surgeries: _________________________________________________________
_____________________________________________________________________
Family Medical History:
Please indicate by noting M (mother), F (father), S (sibling), PGM (paternal
grandmother), MGM (maternal grandmother), PGF (paternal grand father), MGF
(maternal grandfather)
Allergy, asthma or eczema _________
Other: _________________________________________________________
Social influences and behaviours:
Who lives at home? _____________________________________________________
Any pets? Y / N
If yes, what? _________________ How long? _____________ If yes, who? ______________________________ Any behavioural problems? Y / N Onset: ___________________________________ Any night terrors, sleep walking, difficulty sleeping? Y / N Explain: _______________________________________________________________ Age of child when began daycare: __________________________________________ Average number of hours of television/computer/video games per week: ____________ Any difficulty with social interaction? Y / N explain: ___________________________ Extra-curricular activites / hobbies: __________________________________________ Exercise habits: _________________________________________________________ Do the parent(s) / guardian(s) work? Y / N Who? _____________________________ How many hours a week? _____ Number of hours spent with child per week _____ How old is the home? _________ How is it heated? __________________________ Any recent home renovations? _____________________________________________ How long have you been in the present home? ________________________________ Is it located near: trees other: _________________________________________________
General Review of Systems:
Does your child have any rashes, lumps, sores, itching, dry skin, change in hair or nails?
Y / N If yes: ___________________________________________________________________________
Has your child ever been unconscious, had a convulsion, have recurring headaches or
had a head injury?
Y / N If yes: ___________________________________________________________________________
Any problems with hearing, ringing in the ears, dizziness, ear infections, discharge?
Y / N If yes: ___________________________________________________________________________
Any problems with teeth, gums, tongue, sore throats or hoarseness?
Y / N If yes: ___________________________________________________________________________
Any problem with their eyes, including vision?
Y / N If yes: ___________________________________________________________________________
Has your child ever been cyanotic (turned blue), have a cough, wheeze, or asthma?
Y / N If yes: ___________________________________________________________________________
Any recurring problem with vomiting, diarrhea, constipation or stomach pain?
Y / N If yes: ___________________________________________________________________________
Any unusual problem on passing urine or any unusual frequency? Any unusual smell or
appearance to the urine?
Y / N If yes: ___________________________________________________________________________
Does your child complain of any extremity or lower back pain? Y / N
Do you notice a limp, or unusual gait pattern?
Y / N If yes: ___________________________________________________________________________
Has your child ever had blackouts, seizures, weakness, paralysis, numbness or loss of
sensation, tremors, or other involuntary movements?
Y / N If yes: ___________________________________________________________________________
Does your child have any thyroid trouble, excessive thirst or hunger, heat or cold
intolerance, or diabetes?
Y / N If yes: ___________________________________________________________________________
Any allergies, eczema, hay fever, hives or drug reactions?
Y / N If yes: ___________________________________________________________________________
Does you child have any intense fears, mood swings, or other sensitivities?
Y / N If yes: ___________________________________________________________________________
OTHER HEALTH CONCERNS & ADDITIONAL INFORMATION:
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Source: http://www.pathtowellness.ca/assets/forms/Pediatric%20Intake%20Form.pdf