Child Intake Form Child Intake Form Today’s Date: Full Name: Full Address: Mother’s Name: Father’s Name: Main Phone Number: Alternate Phone Number (work/ home): Email Address: * Child’s Birth Date: (MM/DD/YY) Gender: Weight: Height: Family Physician: Emergency Contact: Emergency Contact Phone Number: Relationship to Patient: Family Doctor Name: Family Doctor Phone Number: Other Healthcare Provider: Name of Homeopath if treated previously: Referred by: If currently under the care of another physician, please explain for what condition you are being treated: Child’s main health problems: When did they start? Did the illness start after an event, accident or mental upset, such as shock, worry, dietary, overexertion, weather? Please, explain: What makes it better or worse? Does the child have any other health concerns? If so, please list them in order of importance: List any allergies the child might have: Does the child have any prior conditions after which he/she never felt totally well again? If so, please, explain: FOR MOM: Child’s birth weight: Rh blood problems: Any complications during or after delivery: Number of hours in labor: Was the delivery: Normal Premature Cesarean Forceps Aided At home In Hospital Drug aided Difficult Was this child breastfed: YesNo If yes, how long: Type of formula used: When did the child start eating solids: What foods were introduced first: Did you have any problems conceiving: Was it a stressful pregnancy: Did you experience any of the following: Anemia Fatigue Nausea Vomiting Did you use any of the following during pregnancy: Alcohol Iron Supplements Antibiotics Recreational Drugs Cigarettes Sedatives Sleeping Pills Did you undergo any of the following procedures during pregnancy: X-ray Ultrasounds Any surgeries Were you on a special diet? YesNo Were you on a special diet? If yes, why: Did you have any food cravings or aversions during pregnancy? How much weight did you gain (or lose) during pregnancy: How was your emotional state when pregnant with this child? During the pregnancy, did you suffer any shocks, traumas or losses? FOR CHILD: Do you like to be with your friends or prefer to be alone: Do you prefer to be with your family? Are you confident? Do you feel you are different? Is it easy for you to become angry or irritable? Do you bite your nails? Do you grind your teeth? Did you or do you wet the bed? Do you have any sleeping problems? Are you a nervous person? Do you feel hyperactive? Do you feel lazy? Do you feel unhappy? Do you have difficulties in school? Do you have any fears or worries? What would you like to change about yourself (if anything)? Please, check any of the following conditions your child may have now: Bedwetting Breathing problems Colic Constipation Convulsions Diarrhea Digestive problems Ear Infections Eczema/ rashes Hard to please Heart Murmur Hyperactivity Jaundice Learning problems Much crying Nervousness No energy Sleeping problems Speech problems Tantrums Teeth problems Vision problems OtherOther List previous vaccinations and any adverse reactions: List any treatments, medicines, supplements, homeopathic remedies your child is taking, for how long and their effect on your child: List any major surgeries, date and reason: List any major injuries, date and reason: Family History (what diseases affected your family, these can include:) Alzheimers Alcoholism Asthma: Arthritis Cancer Diabetes Depression Epilepsy Gonorrhea: Hypertension Heart Disease: Hepatitis Mental Illness Pneumonia Skin diseases Syphilis Tuberculosis Ulcers OthersOthers Mother Mother's Current age Mother's Age of death Mother's Cause of death Mother's Disease(s) Maternal Grandmother Maternal Grandmother's Current age Maternal Grandmother's Age of death Maternal Grandmother's Cause of death Maternal Grandmother's Disease(s) Maternal Grandfather Maternal Grandfather's Current age Maternal Grandfather's Age of death Maternal Grandfather's Cause of death Maternal Grandfather's Disease(s) Father Father's Current age Father's Age of death Father's Cause of death Father's Disease(s) Paternal Grandmother Paternal Grandmother's Current age Paternal Grandmother's Age of death Paternal Grandmother's Cause of death Paternal Grandmother's Disease(s) Paternal Grandfather Paternal Grandfather's Current age Paternal Grandfather's Age of death Paternal Grandfather's Cause of death Paternal Grandfather's Disease(s) Sister(s) Sister(s) Current age Sister(s) Age of death Sister(s) Cause of death Sister(s) Disease(s) Brother(s) Brother(s) Current age Brother(s) Age of death Brother(s) Cause of death Brother(s) Disease(s) Aunt(s) Aunt(s) Current age Aunt(s) Age of death Aunt(s) Cause of death Aunt(s) Disease(s) Uncle(s) Uncle(s) Current age Uncle(s) Age of death Uncle(s) Cause of death Uncle(s) Disease(s) Children Children Current age Children Age of death Children Cause of death Children Disease(s) Captcha Submit If you are human, leave this field blank. Δ
