Pediatric Client Intake Form (Page 2 of 4) in pdf

Please list medications, supplements or homeopathics the child is now taking:

Medication/Herb/Etc.

Reason

Started

Dosage

Please mark any of the following that your child now has or has had in the past. Identify the condition and

location where applicable.

Now Past

Condition

Now

Past

Condition



Skin Conditions

Respiratory Conditions

(includes rashes, topical allergies,

(includes sinus, lung and bronchial

fungal infections, etc.)

conditions, etc.)

Type _________________________

Location _______________________



Muscle Conditions

Circulatory Conditions

(includes strains, tendonitis, spasms,

(includes heart, blood pressure,

cramps, etc.)

arteries and venous conditions, etc.)

Type _________________________

Location _______________________



Joint Conditions

Reproductive Conditions

(includes sprain, arthritis, degenerating

(includes pregnancy, prostate,

joints, etc.)

menstruation, etc.)

Type _________________________

Location _______________________



Nervous System Conditions

Digestive Conditions

(includes numbness, tingling, nerve

(includes constipation, diarrhea, ulcers,

damage, shingles, etc.)

etc.)

Type _________________________

Location _______________________



Infectious or Communicable

Other Conditions

Conditions

(includes any other health condition not

previously listed)

Type _________________________

Location _______________________

Other medical conditions, symptoms and/or further explanations: ____________________________________

________________________________________________________________________________________

Page 2 of 4 Child’s Name: _______________________

Pediatric Client Intake Form Page 2

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