Naturopathic Child Intake Form

HART & SOL INTEGRATIVE HEALTHCARE - (289)271-2788

Home
BOOK ONLINE!
Our Team
Services
Patient Forms
Conditions We Treat
Service Fees
Nutritional Supplements
Contact & Hours
COVID-19 Policy
Niagara Natural Fertility

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? *

How did you hear about our clinic? *

Google ad Yellowpages online Niagara Healers website Other internet search Someone told me about your clinic Clinic sign The Peanut Mill Naturally Healthy The Healthy Lifestyle Directory Centre Stage magazine Other

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: *

Has the child had any of the following conditions? *

Rubella (german measles) Measles Chicken pox Mumps Roseola Scarlet fever Whooping cough Strep throat Impetigo Mononucleosis Ear infections

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? *

Please check which immunizations the child has had: *

DPT (diphtheria, pertussis, tetanus) Tetanus booster MMR (measles, mumps, rubella) Haemophilus influenza B Flu vaccine Polio Hepatitis B Hepatitis A Smallpox Varicella/Chicken pox HPV/Gardasil Other

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): *

How was the health of the mother of the child at conception? *

Excellent Good Fair Poor Unknown

How was the health of the father of the child at conception? *

Excellent Good Fair Poor Unknown

How was the mother's health during the pregnancy? *

Excellent Good Fair Poor Unknown

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

How was the mother's diet during pregnancy? *

Excellent Good Fair Poor Unknown

Did the mother receive prenatal medical care? *

Yes No Unknown

Did the mother experience any of the following during pregnancy? *

Bleeding High blood pressure Nausea Vomiting Diabetes Thyroid problems Physical or emotional trauma Other

Did the mother use any of the following during the pregnancy? *

Tobacco Alcohol Recreational drugs Prescription medication Over-the-counter medication Supplements Other

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: *

Were any of the following involved in the birth: *

Vaginal birth C-section birth Induced Forceps Episiotomy Epidural

Did the child experience any of the following at or shortly after birth? *

Jaundice Rashes Seizures Birth injuries Birth defects Other

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: *

How was the child's health in the first year? *

Excellent Good Fair Poor Unknown

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

How is the home heated? *

Forced air gas Radiator heating Electric Wood Other

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? *

Submit

Niagara Naturopathic Doctors, Physiotherapy, and Massage - Hart & Sol Integrative Healthcare

Home
BOOK ONLINE!
Our Team
Services
Patient Forms
Conditions We Treat
Service Fees
Nutritional Supplements
Contact & Hours
COVID-19 Policy
Niagara Natural Fertility