Pediatric Intake

Patient Information
Patient Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Sex*
- Male
- Female
Age*
Birth date*
MM slash DD slash YYYY
Parent/Guardian*
First Last
Occupation*
Phone*
Email*
Parent/Guardian 2*
First Last
Occupation*
Phone*
Email*
In Case of Emergency Contact*
- Parent / Guardian 1
- Parent / Guardian 2
- Other
Other Contact Name*
First Last
Other Contact Relationship to Patient*
Other Contact Phone*
Who may we thank for referring you?

Pregnancy History
Did you experience any complications during your pregnancy? (check all that apply)*
Other (Please Describe)*
Growth & Development
Infant Feeding:
- Breast
- Bottle
- Formula
Number of hours of sleep each night:*
Quality of Sleep:*
At what age did the child respond to sound?*
At what age did the child crawl?*
At what age did the child hold their head up?*
At what age did the child stand?*
At what age did the child sit unsupported?*
At what age did the child walk unsupported?*
Childhood Diseases, Illnesses & Vaccinations
Has your child had (check all that apply)*
Has your child ever suffered from (check all that apply)?:*
Have you ever vaccinated your child?
- Yes
- No
- As Scheduled
- Delayed Schedule
Allergies, Medications, Surgeries & Family History
Allergies (list)*
Medications (list)*
Surgeries (list)*
Family History (list)*

Authorization for Care of Minor
By submitting this form I hereby authorize this clinic and its doctor(s) to administer care as they so deem necessary to my son/daughter/ward.*
- Acknowledge

Patient Information