Good News Naturopathic Clinic

91 East Ave, Norwalk CT 06851

203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________

Pediatric Intake Form

Date: ___________________

Patient Last Name: ____________________________ First Name: _______________________

DOB: ________________ Age: ______ Sex: M F SSN: ______________________

Street Address: ________________________________________________________________

City: _____________________ State: _________________ Zip: ____________________

PARENT/GUARDIAN CONTACT INFORMATION:

Name:____________________ Relationship: ____________ Phone: __________________

Home Phone: ______________ Cell Phone: _____________ Work Phone:______________

Insured? Y N Insurance Provider: _________________________________

Preferred number to reach you: ____________________ OK to leave voicemail? Y N

Parent’s Email address: __________________________________________________________

EMERGENCY CONTACT INFORMATION (in the event parent/guardian cannot be reached)

Name: ____________________ Relationship: _____________ Phone: _________________

How did you hear about us?

 Referral from Health Care Provider – Name: ___________________________________

 Patient Referral – Name: ___________________________________________________

 Nutrition Workshop  Internet Search  Other (please specify): ______________

When did your child’s last receive health care, and for what reason?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Reason for today’s visit: _________________________________________________________

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 Good News Naturopathic Clinic
91 East Ave, Norwalk CT 06851
203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________

Has your child been seen by any other doctor(s) for this health concern? Y P N

Please list your child’s primary health concerns/goals (in order of importance):

1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
5. ________________________________________________________________________

Please list all MEDICATIONS your child is currently taking, including over-the-counter
medications.
 Child does not currently take any medications.
Medication Reason Date/year Dose/Frequency Helpful?
started? Y or N
1.

2.

3.

4.

5.

Please list all SUPPLEMENTS your child is currently taking, including vitamins, minerals,
herbal, and others.
 Child does not currently take any supplements.
Supplement Supplement Date/year Dose/Frequency Helpful?
Name Brand started? Y or N
(ex: Vitamin B12) (ex: Nature’s Way)
1.

2.

3.

4.

5.

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 Good News Naturopathic Clinic
91 East Ave, Norwalk CT 06851
203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________
Please list any known drug, food or environmental allergies:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

MOTHER’S PREGNANCY HEALTH

Age at conception: ____________ First pregnancy? Y N If not, pregnancy # ____________

Smoke Y N Preeclampsia Y N
Coffee Y N Diabetes Y N
Recreational Drug Use Y N Emotional Stress
Nausea/Vomiting Y N

Vaginal Birth Y N
Traumatic Birth Y N If yes, please describe: ________________
______________________________________________________________________________
______________________________________________________________________________

Length of labor: ________

Breast fed: Y N If yes, how long? ________ Formula: Y / N If yes, type: ______________

Did your child satisfactorily meet all developmental milestones? Y / N

If no, please describe setbacks: ____________________________________________________
______________________________________________________________________________

PAST MEDICAL HISTORY Yes (Y), Past (P), No (N)

Has your child been immunized? Y / N If yes, please specify:
Immunization Y or N Date(s) Received
Polio Y N
Measles, Mumps, Rubella Y N
Diptheria Y N
Hepatitis B Y N
Pertussis Y N
Tetanus Y N
Chickenpox Y N
Influenza Y N
Herpes Zoster (Shingles) Y N
Tuberculosis Y N
Pneumonia Y N
Meningitis Y N
Other (specify): Y N

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 Good News Naturopathic Clinic
91 East Ave, Norwalk CT 06851
203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________

Has your child had any adverse reactions to immunizations? Y N

If yes, which one(s) and describe the adverse reaction: _________________________________
______________________________________________________________________________

Hospitalizations: Y / N If yes, please list:

Date Reason Length of Stay
1.

2.

3.

Surgeries: Y / N If yes, please list:

Date Procedure Complications
1.

2.

3.

History of antibiotic use? Y P N If yes, what reason: _______________________________

______________________________________________________________________________

Jaundice as baby Y N Colic Y N

Cradle Cap Y N Anemia Y N
Asthma Y N Eczema Y N
Behavioral issues Y N Bedwetting Y N
Early puberty Y N Excessive sweating Y N
Picky eater Y N Frequent earaches Y N
Irritable Y N Frequent sore throats Y N
Frequent colds Y N

Normal hearing? Y N Never Tested

Normal vision? Y N Never Tested
Speech impediments? Y N Never Tested If yes, describe: ________________________
Learning disabilities? Y N Never Tested If yes, describe: ________________________

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 Good News Naturopathic Clinic
91 East Ave, Norwalk CT 06851
203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________

FAMILY HISTORY
Please indicate whether child or family member(s) has or had any of the following illnesses:

Family Autoimmune Cancer Cardiovascular Diabetes Mood Neurological Thyroid

Member Disease (specify) Disease Disorders Disorders Disease
(specify) (specify) (specify) (specify)
Child Y P N Y P N Y P N Y P N Y P N Y P N Y P N

Mother Y P N Y P N Y P N Y P N Y P N Y P N Y P N

Father Y P N Y P N Y P N Y P N Y P N Y P N Y P N

Sibling(s) Y P N Y P N Y P N Y P N Y P N Y P N Y P N

Maternal Y P N Y P N Y P N Y P N Y P N Y P N Y P N
Grandmother

Maternal Y P N Y P N Y P N Y P N Y P N Y P N Y P N
Grandfather

Paternal Y P N Y P N Y P N Y P N Y P N Y P N Y P N
Grandmother

Paternal Y P N Y P N Y P N Y P N Y P N Y P N Y P N
Grandfather

If death directly resulted from any of the illnesses listed above, please note family member(s)
and age of death: _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

REVIEW OF SYSTEMS
General:
Weakness Y P N Chills Y P N
Fatigue Y P N Night sweats Y P N
Fever Y P N
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 Good News Naturopathic Clinic
91 East Ave, Norwalk CT 06851
203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________

Has your child had a weight gain or loss of 5 or more pounds within the past month? Y N
If yes, how many pounds gained or lost? _____________________________________________

Has your child experienced any changes in appetite? Y N

If yes, describe the changes: ______________________________________________________
______________________________________________________________________________

Have you noticed any changes in your child’s sleeping habits? Y N

If yes, describe the changes: ______________________________________________________
______________________________________________________________________________

Head:
Trauma Y P N Dizziness Y P N
Headaches Y P N Lightheadedness Y P N
Migraines Y P N Hair Loss Y P N

Eyes:
Double vision Y P N Glaucoma Y P N
Blurriness Y P N Photophobia Y P N
Cataracts Y P N Vision changes Y P N
Dryness Y P N Eye pain Y P N

Date of last eye exam: _______________________

Ears:
Earache Y P N Ringing ears Y P N
Discharge Y P N Vertigo Y P N
Hearing loss Y P N Trauma to ear Y P N

Nose:
Sinusitis Y P N Congestion Y P N
Loss of smell Y P N Nosebleeds Y P N
Discharge Y P N Nasal fracture Y P N
Polyps Y P N

Mouth and Throat:

Oral lesions Y P N Difficulty swallowing Y P N
Bleeding/sore gums Y P N Sore throat Y P N
Cavities Y P N Teeth grinding Y P N
Hoarseness Y P N Impaired speech Y P N

Date of last dental exam: _____________________

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 Good News Naturopathic Clinic
91 East Ave, Norwalk CT 06851
203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________

Neck:
Trauma Y P N Swollen glands Y P N
Pain or stiffness Y P N Lumps Y P N
Goiter Y P N

Respiratory:
Asthma Y P N Bronchitis Y P N
Chronic cough Y P N Pneumonia Y P N
Wheezing Y P N Sputum Y P N
Emphysema Y P N Blood in sputum Y P N
Tuberculosis Y P N Shortness of breath Y P N
Difficulty breathing Y P N with lying down Y P N
Rapid breathing Y P N with exertion Y P N
Painful breathing Y P N at night Y P N

Cardiovascular:
High blood pressure Y P N Angina Y P N
Murmur Y P N Chest pain Y P N
Palpitations Y P N Dizziness Y P N
Heart disease Y P N Swollen ankles/feet Y P N
Leg pain (walking) Y P N Rheumatic fever Y P N

Peripheral Vascular:
Coldness of hands/feet Y P N Varicose veins Y P N
Numbness of hands/feet Y P N Spider veins Y P N
Deep leg pain Y P N Thrombophlebitis Y P N

Gastrointestinal:
Heartburn Y P N Belching Y P N
Bloody stool Y P N Gas/bloating Y P N
Gallbladder disease Y P N Hemorrhoids Y P N
Liver disease Y P N Jaunice/yellow skin Y P N
Vomiting Y P N Nausea Y P N
Vomiting of blood Y P N Ulcers Y P N
Rectal pain/itching Y P N Loose stool Y P N

How often is your child having a bowel movement? ___________________________________

Do you notice the following in your child’s stool?
Blood Y P N
Mucous Y P N
Undigested food Y P N

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 Good News Naturopathic Clinic
91 East Ave, Norwalk CT 06851
203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________

Skin:
Acne Y P N Boils Y P N
Itching Y P N Rashes Y P N
Lesions Y P N Hives Y P N
Bruising/color changes Y P N Moles Y P N
Eczema Y P N Dryness Y P N

Genitourinary:
Urge to urinate Y P N Frequent urination Y P N
Blood in urine Y P N Painful urination Y P N
Difficulty urinating Y P N Kidney stones Y P N
Frequent infections Y P N Incontinence Y P N
Urethral discharge Y P N

Male Reproductive System:

Hernia Y P N STDs Y P N
Testicular Pain Y P N Testicular masses Y P N
Sexual/penile dysfunction Y P N Prostate disease/pain Y P N
Discharges/sores Y P N Genital warts Y P N
Infertility Y P N

Female Reproductive System:

Age of first menses: _____________ Normal puberty? Y N
Length of cycle: _____________ Days of bleeding: _________ Regular cycle? Y P N
LMP: _______________________
Birth control? Y P N What type? _______________________________________________
# of Pregnancies: ______ Births: ______ Miscarriages: _________ Abortions: __________
Pregnancy complications? Y N
If yes, please explain: ____________________________________________________________
______________________________________________________________________________

Does your child have:

Painful menses Y P N Painful intercourse Y P N
PMS Y P N Heavy bleeding Y P N
Missed periods Y P N Sexual dysfunction Y P N
Menopause symptoms Y P N STDs Y P N
Pelvic pain Y P N Vaginal itching/burning Y P N
Spotting Y P N Vaginal discharge/sores Y P N
Genital warts Y P N

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 Good News Naturopathic Clinic
91 East Ave, Norwalk CT 06851
203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________
Breast:
Nipple discharge Y P N Enlargement Y P N
Breast pain Y P N Tenderness Y P N
Lumps/mass Y P N Skin discoloration Y P N
Self-breast exams Y P N

Musculoskeletal:
Joint pain/stiffness Y P N Broken bones Y P N
Joint swelling Y P N Muscle cramps/spasms Y P N
Arthritis Y P N Weakness Y P N
Tenderness Y P N Muscle aches Y P N

Neurological:
Numbness/tingling Y P N Seizures Y P N
Fainting Y P N Paralysis Y P N
Tremors Y P N Memory loss Y P N
Loss of sensation Y P N Loss of coordination Y P N

Endocrine:
Hot/cold intolerance Y P N Excessive thirst Y P N
Excessive hunger Y P N Excessive urination Y P N
Easy bleeding/bruising Y P N Anemia Y P N
Low energy/fatigue Y P N

Mental/Emotional:
Anxiety/nervousness Y P N Excessive fears Y P N
Depression Y P N Mood swings Y P N
Easily angered Y P N Restlessness Y P N
Suicidal thoughts Y P N Tension/Stress Y P N

HEALTH HABITS:

Drink alcohol? Y P N If yes, how many drinks a day or week? ___________________________________

Smoke? Y P N If yes, how many cigarettes a day? __________________________________
Recreational drug use? Y P N If yes, please list: ___________________________________
______________________________________________________________________________

Chemical or environmental exposures? Y P N

Please list type of exposure and any symptoms your child has experienced before, during or after
exposure: _____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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 Good News Naturopathic Clinic
91 East Ave, Norwalk CT 06851
203-450-6463 (Tel) 203-900-8747 (Fax)
____________________________________________________________________________________

Does your child currently exercise? Y N

If so, how frequently and what activities? ___________________________________________
______________________________________________________________________________
______________________________________________________________________________

How many hours does your child sleep? __________________________

Does s/he sleep through the night? Y N Does s/he have nightmares? Y N
Does s/he nap throughout the day? Y N
Insomnia? Y N Difficulty falling asleep or staying asleep? (circle one)
Does your child appear to be well-rested when s/he wakes? Y N

Describe your child’s energy on a scale of 1-10 (1=low; 10=high): _______________________

Best time of day? ____________________ Worst time of day? _______________________

Does your child watch TV? Y N If yes, how many hours per day? ______
Does your child play video games? Y N If yes, how many hours per day? ______

Does your child have difficulty with school (i.e. academic performance)? Y N
If yes, please list all escape behavior(s): _____________________________________________
______________________________________________________________________________
______________________________________________________________________________
Is your child stressed at home, school or social events? Y N
If yes, please list all coping mechanisms: ____________________________________________
______________________________________________________________________________
______________________________________________________________________________

Please list your child’s hobbies/interests: ____________________________________________

______________________________________________________________________________
______________________________________________________________________________

Please list any concerns about your child that have not been addressed on this form.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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