Pediatric Intake Form Page 2
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1
2Were any of the following experienced during pregnancy?
Bleeding ____ Physical or emotional trauma ____ High blood pressure____Nausea/Vomiting_____
Cigarettes, alcohol, drug consumption ____ Thyroid problems_____ Illnesses _____ Surgery____
Medications ____ Gestational diabetes____ Depression/Anxiety____ Other_________________
CHILD’S BIRTH HISTORY
Term:
Full
Premature: _____ weeks
Late: _____ weeks Weight at birth:_____lbs, ____ oz.
Length of labor _____________ Any complications?_______________________________________
_________________________________________________________________________________________
Birth:
vaginal
C-section
Induced
Forceps
Suction
Anesthesia used
Did your child have any of the following problems shortly after birth?
Birth abnormality___________________ Birth injuries___________________ Blue baby____ Cerebral
palsy____ Seizures____ Jaundice____ Colic ____ Fever____ Rashes____
Other (explain): ___________________________________________________________________
FEEDING
Breastfed?
yes
no How long? Formula?
yes
no
If Yes:
cow’s milk
soy
other
Child's sleep patterns _______________________________________________________________
How would you describe your child’s temperament?__________________________________________
Food or environmental sensitivities or allergies (if known) _____________________________________
______
________________________________________________________________________________
____
Any dietary restrictions (religious, vegetarian, vegan, etc.)? ___________________________________
Age began solids ______Which foods?___________________________________________________
______
Typical daily diet:
________________________________________________________________
____
________________________________________________________________________________
______
____
Age began: Sitting________ Crawling________ Walking________ Talking________
SYMPTOMS (mark Y if current, P significant past symptom)
Hives
Sleep problems
Easy bruising
Frequent colds
Burning of urine
Acne
Motion/car sickness
Bleeding tendency
Unusual fears
Bloody urine
Anemia
Diarrhea
Eczema
Night sweats
Earaches/Infections
Wheezing
Frequent urination
High fevers
No appetite
Joint pains
Cries easily
Stomach aches
Sore throats
Excessive fatigue
Bleeding gums
Sensitive to light
Constipation
Cough
Heart murmur
Chronic rash
Nightmares
Dizzy spells
Nervous
Jaundice
Headaches
Hair loss
Nose bleeds
Body/breath odor
Gas
Vomiting spells
Hearing loss
Canker sores
Other: ____________________________________________________________________________
Please explain briefly what you would like to see as a result of acupuncture treatments?
____________________________________________________________________________________________
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