Pediatric Intake Form

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Personal Information

Patient Name

First Last

Gender

Male

Female

Age

Please enter a number less than or equal to 99.

Parent or Legal Guardian?

Parent

Legal Guardian

Mother's Name

Father's Name

Legal Guardian Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent or Guardian Email

Preferred Phone Number

Date of Birth

Would you like to receive notices from our office?

Yes

Employer

Occupation

Name of Emergency Contact

Child’s Primary Care Physician:

Person To Be Notified In Case of Emergency:

Relationship:

How did you hear about our office?

Insurance Information

Name of the insurance company?

Subscriber’s name (This could be the child or his/her parents)?

Subscriber’s employer?

Subscriber’s date of birth?

PLEASE LIST THE HEALTH CONCERN/PROBLEM THAT BRINGS YOU IN TODAY:

Health Concern / Problem #1

Describe your concern or problem.

When did this problem initially start to bother your child?

How often does it bother you -- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worst/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem you’d like to share?

Add 2nd heath concern?

Yes, add 2nd concern

Health Concern / Problem #2

Describe your concern or problem.

When did this problem initially start to bother your child?

How often does it bother you -- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worst/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem you’d like to share?

Add 3rd health concern?

Yes, add 3nd concern

Health Concern / Problem #3

Describe your concern or problem.

When did this problem initially start to bother your child?

How often does it bother you -- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worst/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem you’d like to share?

HISTORY OF THIS CONCERN/PROBLEM:

1. Has child received any treatment for this illness?

Yes

If Yes, What

2. Has child ever had this illness in the past?

Yes

If Yes, When

3. How long has he/she had this illness?

Current Medications

Please list any prescription or over the counter medications that your child is currently taking.

Name of Drug

Dose

Reason for Taking

For how long

Who prescribed

Allergic to any drugs or substances? What?

Please list any vitamins, minerals, herbs or homeopathic remedies that your child is presently taking.

Please list your current health care providers.

Name

Type

For what reason

Phone (if available)

Hospitalizations, Serious Illnesses and Injuries

Please list reason and dates.

Event

Reason

Date

IMMUNIZATIONS: (List types, dates given, and any adverse reactions)

Immunization Type

Date Given

Adverse Reactions

SOCIAL HISTORY:

1) Parents:

Single

Married

Separated

Divorced

Mother’s Occupation

Mother's Fulltime / Partime Employment?

Full Time

Part Time

Father’s Occupation

Father's Fulltime / Partime Employment?

Full Time

Part Time

2) Other Guardian:

Guardian Relationship

3) Others Residing in Home:

Others Relationship

4) Siblings:

Name

Age

Health Problems

CHILD’S HEALTH HISTORY (please check)

Acne

Now

Past

Never

Allergies

Now

Past

Never

Anemia

Now

Past

Never

Asthma

Now

Past

Never

Bed Wetting

Now

Past

Never

Birth Defects

Now

Past

Never

Colic

Now

Past

Never

Constipation

Now

Past

Never

Cough/Wheeze

Now

Past

Never

Cradle Cap

Now

Past

Never

Depression

Now

Past

Never

Diarrhea

Now

Past

Never

Dizzy Spells

Now

Past

Never

Earaches

Now

Past

Never

Eczema

Now

Past

Never

Epilepsy/Seizures

Now

Past

Never

Fatigue

Now

Past

Never

Frequent Infections

Now

Past

Never

Headaches

Now

Past

Never

Heart Murmur

Now

Past

Never

High Fever

Now

Past

Never

Hyperactivity/ADD

Now

Past

Never

Insomnia

Now

Past

Never

Jaundice

Now

Past

Never

Learning Difficulties

Now

Past

Never

Moodiness

Now

Past

Never

Stuffy Nose

Now

Past

Never

Thrush

Now

Past

Never

Vomiting Spells

Now

Past

Never

Other

Now

Past

Never

CHILDHOOD ILLNESSES (Please check and indicate at what age)

Leave blank if the child has never had the illness.

Chicken Pox Age

Measles Age

Mumps Age

Rubella Age

Whooping Cough Age

Scarlet Fever Age

Rheumatic Fever Age

Strep Throat Age

Pneumonia Age

Asthma Age

Mononucleosis Age

Ear Infections Age

Tonsillitis Age

Croup Age

Other Childhood Illnesses

Illness

Age

FAMILY HISTORY: Identify all family members who have or have had any of the following:

Alcoholism

Allergies

Anemia

Arthritis

Asthma

Birth Defects

Cancer

Diabetes

Eczema

Epilepsy

Stroke

Obesity

High Blood Pressure

Hypoglycemia

Mental Illness

Thyroid disorder

Heart Disease

Hearing Loss

Other (Describe)

Illness / Disease

Relationship

PRENATAL/ BIRTH HISTORY:

MOTHER’S health during the pregnancy with this INFANT/ CHILD/ ADOLESCENT (check and describe in space provided):

Age

Trauma/Injury

Alcohol Consumption

Illness

Bleeding

Stress

Nausea

Drugs

Smoking

X-rays

High Blood Pressure

Toxemia

Medications

Other

Term:

Full

Premature

Late

Was birth / pregnancy:

Yes

Birth Weight:

LBS

Place of Birth:

Hospital

Home

Clinic

Other

Other Place of Birth

Method

HABITS:

1) Does your child eat a special diet?

2) What are your child’s favorite foods?

3) What is your child’s general disposition?

4) How much does your child sleep?

5) Does your child wear:

Cloth Diapers

Disposable

None

6) Date of last check-up

Date of last check-up: Doctor

7) List any chemicals, metals, dusts, smoke or fumes your child has been repeatedly exposed to:

8) Does your child react to pollens? If so, then which ones?

9) Does your child react to foods? If so, then which ones?

Feeding

Choose appropriate boxes

MOTHER’S MILK: (or weaned when?)

Never

Rarely

Frequently

Weekly

MOTHER’S MILK: Times Per Day

MOTHER’S MILK: Date Weaned

MILK OR FORMULA

Never

Rarely

Frequently

Weekly

MILK OR FORMULA: Times Per Day

MILK OR FORMULA: Kind

SUGAR SWEETS

Never

Rarely

Frequently

Weekly

SUGAR SWEETS: Times Per Day

FRUIT SWEETENERS

Never

Rarely

Frequently

Weekly

FRUIT SWEETENERS: Times Per Day

WHITE FLOUR

Never

Rarely

Frequently

Weekly

WHITE FLOUR: Times Per Day

PROTEIN FOODS

Never

Rarely

Frequently

Weekly

PROTEIN FOODS: Times Per Day

PROTEIN FOODS: List kinds of foods

VITAMINS-MINERALS

Never

Rarely

Frequently

Weekly

VITAMINS-MINERALS: Times Per Day

VITAMINS-MINERALS: List kinds of Vitamins-Minerals

ASPIRIN

Never

Rarely

Frequently

Weekly

ASPIRIN: Times Per Day

LAXATIVES

Never

Rarely

Frequently

Weekly

LAXATIVES: Times Per Day

ARE YOU WILLING TO CHANGE YOUR HABITS TO HELP IMPROVE YOUR CHILD’S HEALTH?

DOES YOUR CHILD HAVE ANY OTHER PROBLEMS YOU WOULD LIKE TO DISCUSS WITH THE DOCTOR?

IMPORTANT:

Please prepare a half-page to one-page summary outlining what you would like to discuss with Dr. Sharif during your visit. A brief history of your condition(s)—such as when symptoms began, how they have progressed, and any treatments you’ve tried—would be especially helpful.