Paediatric Intake Form ......................Today's Date:


Name: .............................................................Birthdate:

Parent's Name (mother):......................................Parent's Name (father):

Phone Number:

Address:

Name & address of family doctor:

Are you under the care of a physician now? ...........Yes.... No

If yes, for what?

Height:

Weight:

Referred by:

Reason for visit today

Is it getting worse?.............................................Yes.... No

Does it affect your:....................sleep?.................daily activities?.............other? (please specify)

What seemed to be the initial cause?

What makes it better?

What makes it worse?

Other current treatments:


Family Medical History

Has your child been immunized for the following? (please tick all that apply)

diptheria
tetanus
pertussis
polio
measles
rubella
chicken pox
mumps
other (please specify)

Please indicate if there was any side effect from any of the above immunizations


Child's Past Medical History (please check any of the following conditions you currently have, or have had in the past)

jaundice
cold sores
scarlatina
rhinitis
pneumonia
strep throat
oral thrush
rubella
bronchitis
asthma
allergies
impetigo
fever
measles
canker sores
colic
hives
diptheria
nosebleed
conjunctivitis
tonsillitis
bedwetting
eczema
ADHD
epilepsy
mumps
ear infections
tourettes
arthritis
other (please specify)


Surgeries (list)

Major Trauma (car accident, fall, etc.)

Is your child currently on any prescribed medicine? ........Yes.... No

Is your child currently taking any non-prescribed medicine (for i.e. herbs, vitamins, supplements etc.)? ....Yes.... No

Has your child taken antibiotics before? .......................Yes.... No
Number of times:

Excluding the above listed medicine has your child taken any other medicine in the past?


DIET (please complete the sample menu according to an average day)

Morning

Noon

Evening

Snacks (when and what)

Does your child eat or drink the following (if so how often)?
Juice
Ice Cream
Peanut Butter
Raw Vegatables
Milk
Cheese
Breads
Sweets and Sugar

Was your child breast fed? .........Yes.... No

When and how did you introduce solid food?