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OLD / BACKUP OF CHILD INTAKE FORM

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Please fill out every field that applies.

Child’s Full Name: *
Child’s Birthday:

 Year

Child’s Sex Female
Male
Child’s Address: City:

Postal Code:

Caregiver’s Name(s): *
Caregiver’s Address: If Different from above
Phone Home:*
Emergency Phone:
Siblings-Names & Ages:
Family Doctor/Pediatrician Name and Address
What are your major concerns about your child’s health?
What are your other concerns about your child’s health?
Have any of the above conditions been diagnosed? Yes
No
If so, by whom?

Medical History

How would you describe your child’s general state of health?? Good
Fair
Poor
Which of the following illnesses has your child had?
Rubella (German Measles) Never
Mild
Average
Severe
Roscolla Never
Mild
Average
Severe
Impetigo Never
Mild
Average
Severe
Measles Never
Mild
Average
Severe
Scarlet Fever Never
Mild
Average
Severe
Mononucleosis Never
Mild
Average
Severe
Chicken Pox Never
Mild
Average
Severe
Impetigo Never
Mild
Average
Severe
Ear Infections Never
Mild
Average
Severe
Mumps Never
Mild
Average
Severe
Whooping Cough Never
Mild
Average
Severe
Please list any medications, including over-the-counter, vitamins, homeopathics, herbs, etc. taken in the past:
Please list any present medications, including over-the-counter, vitamins, homeopathics, herbs, etc.
Please list your child’s immunizations: Diphtheria/Pertussis/Tetanus, Tetanus Booster, Measles/Mumps/Rubella, Haemophilus Influenza B, Flu, Hepatitis, Polio, OtherPlease list all that apply:
What was the date of the Tetanus Booster Shot?
Please indicate if any immunization caused adverse reactions:
How many times has your child had Antibiotics?
For what reason?:
Dental History or cavities:
List all locations of child’s scars.

Prenatal Health

How was the health of the mother during pregnancy Poor
Fair
Good
Excellent
Unknown
Mother’s Age at Child Birth:
How was the mother’s diet during pregnancy? Poor
Fair
Good
Excellent
Unknown
Did the mother receive pre-natal medical care? Yes
No
Unknown
Did the mother experience any of the following during pregnancy: Bleeding, High Blood Pressure, Nausea, Vomiting, Diabetes, Thyroid, Physical or Emotional Trauma or Other SymptomsPlease list all that apply:
Explain Other maternal symptoms?
Did the mother use any of the following during pregnancy: Tobacco, Alcohol, recreational drugs, Prescription drugs, Over the Counter Medication, Supplements, OtherPlease list all that apply:
Please give details of use of any of the above:
BIRTH HISTORY
Term Length Full
Premature
Late
If premature or Late, by how many weeks?
Length of labour
Baby’s Weight at Birth
Any complications?
Was the birth: Vaginal, C-Section, Induced, Forceps, Anesthesia UsedPlease list all that apply:
Did the baby experience any of the following symptoms after the birth? Jaundice, Rashes, Seizures, Birth Injuries, Birth Defects, OtherPlease list all that apply:
If “Other” please explain:
DIET
How was your baby fed? Breast, Milk Based Formula, Soy Based Formula, OtherPlease list all that apply:
If “Other” please explain:
If you breast fed, how long did you continue?
What foods were introduced before 6 months? Please list approximate months as well.
Foods 6 – 12 Months.
Did your child ever experience colic? Yes
No
How Severe Was the Colic?Mild
Moderate
Severe
Does your child have any food allergies or intolerances? Please List
Do either of the parents have a chronic illness? Yes
No
Please describe parent’s chronic illness
Does your child have any dietary restrictions (religious, vegetarian/vegan?)
TYPICAL DAILY FOOD INTAKE
Breakfast.
Lunch.
Dinner.
Snacks.
Beverages-Total-Quantity.

Anything You Would Like to Add

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