Download Pediatric Intake Form - Ana Lopez, Naturopathic Physician

303-2083 Alma St.
Vancouver, BC, V6R 4N6
604-568-9210
www.jerichoclinic.ca
Pediatric Intake Form
Child’s Name:_________________________________________________________________
Child’s Age: _______________ Date of Birth: ______________________________ Sex: M F
Child’s Height: ____________ Weight: ________________ Grade Level: _________________
Today’s Date: _____________ Referred by: ________________________________________
Who is filling out this form (name and relation): ______________________________________
How did you hear about this clinic: ________________________________________________
Contacts (in order of preference)
Name and relation to child: ______________________________________________________
Phone: (home) _______________________ (work) ___________________________________
Phone: (cell or other) ___________________________________________________________
Address: _____________________________________________________________________
Name and relation to child: ______________________________________________________
Phone: (home) _______________________ (work) ___________________________________
Phone: (cell or other) ___________________________________________________________
Address: _____________________________________________________________________
Whom does the child live with? ___________________________________________________
Child’s Other Health Care Providers
Provider’s name: ______________________________________________________________
Designation (e.g., pediatrician, family physician, etc.): _________________________________
Address (if available): __________________________________________________________
__________________________________________ Phone:____________________________
Provider’s name: ______________________________________________________________
Designation: ________________________________________________________________
Address (if available): __________________________________________________________
__________________________________________ Phone:____________________________
Health Concerns
Please list your child’s health concerns in order of importance.
1. Primary health concern: _______________________________________________________
____________________________________________________________________________
What, if any, medications or supplements have been used to treat this condition and what was
their effectiveness? ____________________________________________________________
____________________________________________________________________________
Other health concerns:
2. __________________________________________________________________________
3. __________________________________________________________________________
4. __________________________________________________________________________
Prenatal Health and History
What was the health of the parents at the time of conception (please circle)?
Mother:
Poor Fair Good Excellent Unknown
Father:
Poor Fair Good Excellent Unknown
What was the health of the mother during pregnancy?
Poor Fair Good Excellent Unknown
What was the mother’s age at the time of the child’s birth? _____________________________
How many previous pregnancies and births did the mother have? ________________________
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 pregnancy?
 Tobacco  Alcohol  Recreational drugs: _______________________________________
 Prescription medications: ______________________________________________________
 Over-the-counter medications: __________________________________________________
 Vitamins and/or supplements: __________________________________________________
 Other: _____________________________________________________________________
Birth History
Term length:  Pre-term (37 weeks or less):
__________weeks
 Full-term (38-42 weeks):
__________weeks
 Post-term (more than 42 weeks): __________weeks
Location of birth:  Hospital  Home  Birthing Center  Other: ____________________
Were there any complications during delivery (e.g., breech delivery)? _____________________
____________________________________________________________________________
Length of labour: __________ Weight of infant at birth: ________________________________
Did the child experience any of the following at or shortly after birth?
 Jaundice  Rashes
 Seizures
 Birth injuries: ______________
 Infections:  Difficulties with feeding  Birth defects
 Other: ____________________
Dietary History
 Breast fed. How long? _________  Formula. Milk/Soy/Other: _______________________
 Other: _____________________________________________________________________
Did your infant experience any reactions to the formula or breast milk? ____________________
____________________________________________________________________________
What foods were introduced before 6 months? Please list the approximate month that each
food was introduced, as well as any reactions that may have occurred.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Did your child ever experience colic? Yes No
Does your child have any food allergies or intolerances? Please list.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Does your child have any dietary restrictions (vegetarian/vegan, religious, etc.)?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Medical History
Has your child ever experienced any of the following illnesses?
 Rubella
 Mumps
 Chickenpox
 Whooping Cough
 Scarlet Fever
 Polio
 Other: ________________________
 Measles
 Asthma
 Rheumatic Fever
Has your child received any of the following vaccinations?
 DPT
 MMR
 HIB
 Polio
 TB
 Flu
 Smallpox
 Pneumovaccine
 Chickenpox
 Other: _____________________________________________________________________
Did your child have any adverse reactions to, or chronic illness following vaccination? ________
____________________________________________________________________________
____________________________________________________________________________
Has your child ever been hospitalized? Yes No If yes, for what and for how long? ________
____________________________________________________________________________
Is your child currently taking any medications or supplements? Please list.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Does your child have any known drug allergies?______________________________________
Health and Development
How was your child’s health in the first year? Poor Fair Good Excellent Unknown
How is your child’s health now? Poor Fair Good Excellent Unknown
Social Patterns
Is your child in: school daycare home care other: __________________________________
How would you describe your child’s behaviour at school? ______________________________
____________________________________________________________________________
How would you describe your child’s behaviour at home? ______________________________
____________________________________________________________________________
Does your child exercise regularly? Yes No
How much and how often? ________________
____________________________________________________________________________
Family History
Indicate if a close relative (parent, grandparent, sibling) has had any of the following:
Condition
Relative
Condition
Relative
 Allergies
 Seizures
 Anemia
 Stroke
 Arthritis
 Diabetes
 Asthma
 Eczema
 Birth Defects
 Glaucoma
 Bleeding Disorder
 Kidney Disease
 Cancer
 Psoriasis
 Hay Fever
 Depression
 High Blood Pressure
 Tuberculosis
 Juvenile Arthritis
 Mental Illness
 Other:
 Other:
_________________
___________________
_________________ _______________
 I don’t know the family medical history
Please fill in the following chart, based on the child’s relatives:
Relation
Age (if living)
Died? At what age? Cause of Death?
Mother
Father
Brother(s)
Sister(s)
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
Environment
Are there any pets in the home? Yes No What type and how many? ___________________
____________________________________________________________________________
Does anyone in the child’s household smoke? Yes No
How is the child’s home heated? __________________________________________________
Is there anything that you feel is important that has not been covered? ____________________
____________________________________________________________________________
____________________________________________________________________________
DECLARATION AND CONSENT TO TREAT
This is to acknowledge that I, the parent/legal guardian) have been informed and understand that:
Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic
doctors assess the whole person, taking into consideration physical, mental, and emotional aspects of an
individual. A number of different approaches are used: diet and nutritional supplements, botanical
medicine, homeopathy, traditional Chinese medicine and acupuncture, hydrotherapy, physical medicine
and lifestyle counselling.
Dr. Ana Lopez will take a thorough case history, and perform a screening physical exam before
developing an individualized treatment plan. If necessary, more specific physical examinations may be
conducted. Certain laboratory assessments may also be required on a case specific basis.
Even the gentlest therapies can sometimes cause complications. There are some slight health risks to
naturopathic medicine. These include, but are not limited to:
· Aggravation of pre-existing symptoms
· Allergic reactions to supplements or herbs
· Pain, bruising or injury from venipuncture or acupuncture
· Fainting or puncturing of an organ with acupuncture needles
· Accidental burning of skin from the use of moxa
As a patient of Dr. Ana Lopez, I am at liberty to seek or continue medical care from a medical doctor or
other health care providers licensed to practice in British Columbia. No employee, agent, board member,
student, instructor or anyone else under the direction or control of Dr. Lopez, has suggested or
recommended that I refrain from seeking or following the advice of another licensed health care provider.
The treatment and therapies rendered or recommended by Dr. Lopez may be different than those usually
offered by a medical doctor or other licensed health care provider.
As a patient of Dr. Lopez, I understand that results are not guaranteed.
The initial pediatric consultation is one hour in length and the cost is $100. Subsequent visits,
acupuncture or Bowen therapy visits are $65. I agree to pay my full account at the time of each visit or
treatment, including fees for services, cost of supplements and remedies, laboratory fees, and any other
fees, unless otherwise discussed with Dr. Lopez. Payment can be made in cash, cheque, visa,
mastercard or debit. Many extended health care providers cover Naturopathic treatments. Please check
with your employer to determine the amount that is covered under your policy.
I understand that treatment advice will not be given over the phone unless directly relating to specifics
discussed during a clinic visit.
I understand that a 24 hour cancellation policy is in effect. To avoid a visit charge, I will notify the office 24
hours before a scheduled appointment.
This consent form is intended to cover the entire course of treatment for my child’s condition. I
understand that I am free to withdraw my consent and to discontinue participation in these procedures at
any time.
Date________________________ _____Patient’s Name ______________________________________
Signature of Patient or Parent/ Legal Guardian: _____________________________________
Signature of Witness: ________________________________________