Naturopathic Child Intake Form

* Indicates required field

Date *

Who is filling out this form? (please provide your name and relation to the child) *

Name of child *

First

Last

Date of birth *

Gender *

Male Female

Child's address *

Line 1

Line 2

City

State

Zip Code

Country

Name(s) of child's main contact *

Address of child's main contact, if different from the child's address *

Line 1

Line 2

City

State

Zip Code

Country

Phone number(s) of child's main contact *

Email *

What is the best method of contact during business hours in regards to the child? *

Phone Email

Name of child's alternate contact (optional) *

Address of child's alternate contact (optional) *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number of child's alternate contact *

With whom does the child live? *

Please list the child's other healthcare providers (name, specialty, phone number) *

What are the child's health concerns, in order of importance: *

How would you describe the child's general state of health? *

Excellent Good Fair Poor

Please indicate any serious conditions, illnesses or injuries, and any hospitalizations, along with dates: *

Does the child have any allergies? (medications, foods, animals, environmental, etc) *

Please list all current medications (prescription, over-the-counter, vitamins, herbs, homeopathics, etc): *

Please list past prescription medications: *

How many times has the child been treated with antibiotics? *

Did any immunizations cause an adverse reactions? If so, please indicate which and what the reaction was: *

Please indicate which screening tests the child has had (blood, hearing, vision, etc): *

What was the mother's age at the child's birth? *

Did the mother receive prenatal medical care? *

Yes No Unknown

Was the birth: *

full term premature late

If the birth was premature or late, please indicate how many weeks: *

What was the length of labour? *

What was the child's weight at birth? *

Were there any complications during labour/birth? If so, please describe: *

How was the child fed as an infant? *

Breastfed Formula Both Other

What foods were introduced before 6 months? *

What foods were introduced between 6-12 months? *

Did the child ever experience colic? *

Yes No

Does the child have any food allergies or intolerances? Please list. *

Does the child have any dietary restrictions (religious, vegan, etc)? *

Describe what the child's typically eats and drinks in a day: *

What age did the child first sit up? *

At what age did the child first crawl? *

At what age did the child first walk? *

At what age did the child first talk? *

Describe the child's sleep pattern: *

How would you describe the child's behaviour and performance at school? *

FAMILY HISTORY (list each health condition in the family and the member(s) associated with it): *

Do either of the child's parents have a chronic illness, if so please describe: *

Is the child in: *

School Daycare Home care Other

What are the child's favourite activities? *

Does the child exercise? If so, please indicate how often: *

How many hours per week does the child watch television? *

How often does the child read (not for school) or how often does someone read to the child? *

Daily Several times a week Once a week Less than once a week

Does anyone in the child's household smoke? *

Yes No

Are there animals in the child's home? *

Yes No

Do you know of any toxins or other hazards the child is regularly exposed to? Please describe: *

How would you describe the emotional climate in the child's home? *

Is there anything that you feel is important that has not been covered? *

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