Pediatric Intake Form printable pdf download

Monica Edlauer, MSOM, LAc.

2955 Valmont St, Ste. 100,

Boulder, CO 80301

(303) 859-7556

Pediatric Intake Form

Patient's name: ______________________________________Date of first visit: ______________

Age: Date of Birth (month/day/year): _____/_____/_____ Gender:

female

male

Mother's name: _______________________Father's name:________________________________

Address: ____________________________City:____________________ Zip: ________________

Phone # (home): (_____)________________ Parent’s work/cell phone # (_____)_______________

Parent’s e-mail address: ____________________________________________________________

Child’s GP or Pediatrician: __________________________________________________________

Current health concerns: __________________________________________________________

_______________________________________________________________________________________

MEDICAL HISTORY

Chicken pox ____ Scarlet fever _____ Roseola _____ Mononucleosis ______ Measles _____ Pneumonia

_____Strep throat _____ Impetigo_____ Mumps _____ Whooping Cough _____ Ear Infections_____

Rubella _____ Rheumatic fever_____ other (please list) ___________________________________

________________________________________________________________________________________

What screening tests has your child had? (blood, hearing, vision, etc)__________________________

Serious Illnesses/Injuries/Surgeries/Hospitalizations (please list): ___________________________

________________________________________________________________________________________

Please list all current medications (prescription, over the counter, vitamins, herbs, homeopathics, etc.)

_______________________________________________________________________________

Please list any past prescription medications: _____________________________________________

_______________________________________________________________________________

IMMUNIZATIONS

MMR _____ Polio _____ Prevnar _____ Chicken Pox _____ H. Influenza B _____ DTaP _______ Influenza

_____ Hepatitis B _____ Hepatitis A _____ Other: __________________________

Any adverse reactions to vaccines:

yes

no If yes, please describe: ___________________________

________________________________________________________________________________

FAMILY HISTORY

Heart disease ____ Diabetes____ Birth abnormality ____ Celiac disease ____ Hypertension ____

Arthritis ___Tuberculosis ___ Eczema____ Cancer _____Allergies ____ Mental illness _____ Asthma____

Other: __________________________________________________________

BIRTH MOTHER’S PRENATAL HISTORY

Mother's age at child's birth? _____ Mother's health during pregnancy? _________________________

Pediatric Intake Form