Pediatric Health History Intake

Pediatric Intake

Patient's information

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal

HEALTH HISTORY

Past Treatments

Please list current prescriptions, over the counter medications, supplements and vitamins

Major Hospitalizations, Surgeries, Injury, Major Medical Diagnosis

Check all of the Current and Past conditions of your child

Current
Past

VACCINATION HISTORY

Please indicate which vaccinations received

FAMILY HISTORY

Check any the following that a family member has experienced

PRENATAL HISTORY

Check any of the following that applied to the pregnancy

Indicate the general health/well-being of the parents during the pregnancy:

Mother
Father

Indicate the general emotional well-being of the parents during the pregnancy

Mother
Father
Mother's diet during pregnancy?

EARLY CHILDHOOD HISTORY

Indicate if any of the following interventions were applied
Indicate if any of the following were present shortly after birth

DEVELOPMENTAL AND SOCIAL HISTORY

At what age did your child first:

Is your child in:

How many hours/weekly does your child:

LIFESTYLE HABITS

Does your child nap during the day?
Does your child have nightmares?
Is the child exposed to any of the following on a regular basis?
Source of your child's drinking water
Marital status of the child's parents

Thank you for taking the time to fill out these forms. I look forward to working with you and your child on your journey to health and well-being.

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