Pediatric Intake Form (Birth To 12 Years)
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2487 Davie Street Vancouver, BC V6B 2G2 Ph:(604) 697-0397 Fax:(604) 697-0883
PEDIATRIC INTAKE FORM (Birth to 12 years)
Patient's name:
Date of first visit:
Age:
Date of Birth (month/day/year): _____/_____/_____
Gender:
female
male
Parent:
Parent:
Address:
City:
Province: ___ Postal Code:
Telephone # home ( ) mobile ( ): (_____)________________ Parent’s work # (_____)________________
Parent’s e-mail address:
How did you hear about Sage Clinic?
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
_____ MMR
____ Smallpox
____ H. Influenza B
_____ DPT
_____ 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 Other: ___________
___Hypertension
___Arthritis ___Tuberculosis
___ Eczema
Other: ____________
___Cancer
___Allergies ___Mental illness
___ Asthma
Other: ____________
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