Pediatric Intake Form (Birth To 12 Years) Page 2
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1
2BIRTH MOTHER’S PRENATAL HISTORY
Mother's age at child's birth? ______
Mother's health during pregnancy? ____________________________________________________________
Were any of the following experienced during pregnancy?
_____ Bleeding
_____ Physical or emotional trauma
____ High blood pressure
_____ Nausea/Vomiting
_____ Cigarettes, alcohol, drug consumption
____ Thyroid problems
_____ Illnesses
_____ Medications
____ Gestational diabetes
CHILD’S BIRTH HISTORY
Term:
Full
Premature _____ weeks
Late _____ weeks
Weight at birth
Length of labor
Any complications?
Birth:
vaginal
C-section
Induced
Forceps
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 allergies (if known) _____________________________________________________
Any dietary restrictions (religious, vegetarian, vegan, etc.)? _______________________________________
Age began solids
Which foods?
Age began: Sitting
Crawling
Walking
Talking
SYMPTOMS (mark C if current, P significant past symptom)
Hives
Burning of urine
Bloody urine
Eczema
Frequent urination
Cries easily
Bleeding gums
Heart murmur
Nervous
Nose bleeds
Vomiting spells
Sleep problems
Acne
Anemia
Night sweats
High fevers
Stomach aches
Sensitive to light
Chronic rash
Jaundice
Body/breath odor
Hearing loss
Easy bruising
Motion/car sickness
Diarrhea
Flat feet
No appetite
Sore throats
Constipation
Nightmares
Headaches
Gas
Canker sores
Frequent colds
Bleeding tendency
Unusual fears
Wheezing
Joint pains
Excessive fatigue
Cough
Dizzy spells
Hair loss
Other: ________________________________________________________________________________
What expectations do you have of being a patient of Sage Clinic?
What expectations do you have of me as your physician?
Thank you. We look forward to helping your child in any way we can.
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