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Download Michelle Obertacz, ND, LAc Northwest Holistic Medicine 7214
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Michelle Obertacz, ND, LAc Northwest Holistic Medicine 7214 Linden Ave N. Seattle, WA 98103 P: (206) 226-8418 F: (206) 260-9245 Pediatric Intake Form DOB______/______/_____ Age ____ Gender ____ Grade _____ Current School _____________________ Last Name______________________________First Name __________________________M.I._________ Mailing Address _________________________________________________________________________ City State Zip Phone___________________________________ You may leave messages at this number Y/N (circle one) Emergency Contact______________________ Phone_______________ Relationship _________________ Mother’s full name ___________________ Father’s full name_________________ Guardian___________ Primary Health Concern Secondary Health Concern ______________________________________________________________________________________ Medical Insurance/Billing Information (please review the patient contract for more information about billing policies and insurance billing) I do not have medical insurance/ my plan does not cover these services and I will be paying at time of service (initial)___________ I have a health insurance plan that I would like billed for patient visits and services (initial)___________ Current Health Insurance Plan: Name___________________________________________ ID#_________________________________ Group #_____________________________ Primary Member Name_____________________________ Relationship to patient ________________________ I have a secondary insurance plan Y/N (circle one) DOB________________ Birth History Mother’s Age at child’s birth ______ Prolonged Labor __________ Surgical Intervention ______________ Adopted _____ From Country ___________ Mother’s health during pregnancy (please check all that apply): ___ Bleeding ____ Hypertension ____ Illness ____ Nicotine Use ___Alcohol Use ___ Drug Use ___Nausea ___Diabetes ___Thyroid Problems ___Physical and/or emotional trauma ___ Bed rest ___Other (explain) ______________________________________________________________________ Was your labor and birth experience a positive one ________ Did/Do you have any postpartum difficulties ______________________________________________________________________________________ Name of last Doctor ______________________________________ Date of last Physical ______________ Hospitalizations Year Reason Year Reason ______________________________________________________________________________________ Surgeries Year Reason Year Reason ______________________________________________________________________________________ Current Medications Prescription ____________________________________________________________________________ Non- Prescription _______________________________________________________________________ Diet Does your child follow a special diet? If yes, explain ____________________________________________ ______________________________________________________________________________________ Exercise Type _____________________________ Number of times/week_________ For how long? ____________ Allergies Known Allergies to Medications ____________________________________________________________ Severe Allergic Reactions to Chemicals, Environment, or Foods ______________________________________________________________________________________ Health History Check all that apply: ___chronic or recurrent illness ___frequent headaches ___ head injury ___frequent ear infections ___frequent bruising ___fainting ___breathing difficulties ___ chest pain ___ frequent vomiting ___frequent stomach pain ___ constipation ___diarrhea or loose bowel movements ___diagnosed with a heart murmur ___joint pain ___ skin rashes ___diabetes ___ asthma ___ abnormal menstrual cycle ___seizures ___kidney/bladder infections ___eating disorder ___emotional and/or behavioral difficulties ___sleep problems/night terrors ___ other(explain)___________________________________________ Common Childhood Illnesses Check all that apply: ___German Measles ___Measles ___Mumps ___Scarlet Fever ___Chicken Pox ___ Rheumatic Fever ___Bronchitis ___Croup ___Whooping Coup ___Hand-Foot Mouth Disease ___Molluscum Contagiosum Vaccination History Provide Dates Given If Known Dtap TD Tetanus Polio XXXXXX HIB MMR XXXXX Hepatitis B Varicella (chicken pox) Other XXXXX XXXXX XXXXXX XXXXX XXXXX XXXXXX XXXXX XXXXX XXXXXX XXXXX XXXXX XXXXXX
