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PEDIATRIC INTAKE FORM

Required fields are indicated with ‘ * ‘. Do not enter special characters for example ( $ , % # ).

Childs Name:* ______________________________

Today’s Date:  (mm/dd/yyyy) _______________

Date of Birth:*  (mm/dd/yyyy) _____________  Age: *______  Gender:*  (M / F)

School: * ______________________________________________________________

Grade: *  _________  Teacher: * _______________________________________

Address:* ________________________________________________________________________________________

City:*  State: *  Zip Code: * 

Parent / Guardian Contact Number 
Telephone: 
*________________________  Mobile: * ____________________________________

Email Address:* ______________________________________________

Relationship to Child : * _____________________________________________________________________

( Guardian / Mother / Farther / Grandparent / Relative)  * _________________________________________________________________________

Reason for referral or presenting problems: * __________________________________________________________________________________

Do you have any concerns about your child’s behavior or development ?  Y/N

If yes, what? __________________________________________________________________________________________________________

What are your main concerns about your child ?* _______________________________________________________________________________

Medical History: *

( Chicken Pox, Scarlet Fever, Tonsillitis, Measles, Pneumonia, Ear Infections, Mumps, Frequent Colds, Strep Throat, Rubella, Rheumatic Fever, Torticollis ) *

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Other: ______________________________________________________________________________________________________________

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Has your child ever had any of the following? __________________________________________________________________________________

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 ( Psychological, Eye/Hearing Test, Speech/Language Test, Physical Therapy )

(WHEN/ WHERE/ RESULTS) _____________________________________________________________________________________________

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Injuries/surgeries/hospitalizations (please list):* _______________________________________________________________________________

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Current Medications: * __________________________________________________________________________________________________

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Allergies: *  __________________________________________________________________________________________________________

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Birth History: *  _______________________________________________________________________________________________________

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 (Term, Full, Premature, Late)

Birth Weight: * ________________  lbs./oz.

Pregnancy Complications / Delivery: *  _______________________________________________________________________________________

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Did your child have any of the following problems shortly after birth? ________________________________________________________________

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( Rashes , Birth Injuries, Blue Baby, Jaundice, Seizures, Cerebral Palsy, Colic, Fever, Birth Defects)

Other:  ______________________________________________________________________________________________________________

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 Please describe your child’s typical daily diet.

Breakfast: ___________________________________________________________________________________________________________

Lunch: ______________________________________________________________________________________________________________

Dinner: _____________________________________________________________________________________________________________

Snacks: _____________________________________________________________________________________________________________

To Drink: ____________________________________________________________________________________________________________

Food Intolerances:  _____________________________________________________________________________________________________

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