New Patient Intake Form - Child | Naturopathic Doctor in Ottawa

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Gender
Date Of Birth
MM
DD
YYYY
Parent/Legal Gardian*
First Last
How did you hear about us?
- Revivelife Patient Referral
- Brochure, Business Card
- Media (Radio, Newspaper, TV)
- Social Media (Facebook, Twitter, LinkedIn)
- Workshop/Seminar
Would you like to receive our newsletters via email?*

How would you describe your child's general state of health?
Please list any allergies, sensitivities, and symptoms associated
Medications/Supplements: Please list all medications/supplements that were taken during pregnancy and those your child is currently taking, or has taken in the last year.
Please list your Health Concerns in their order of Significance
How long has your child had this condition?
If there is one, what is the Medical Diagnosis?
When was the diagnosis made?
What Specialist have you seen?
What has the treatment been to date?
Please list any other Health Concerns
Health Concern Onset Date Diagnosis made by Degree of concern Treatment to date
Please list any medical conditions, surgeries, hospitalizations from most recent to least
Date Event Treatment Precentage of Recovery

Pregancy, Child's Birth & Infancy
Mother - During Pregnancy
General health prior? Health During Pregnancy? Cigarettes? if yes, how much Alcohol? if yes, how much Emotional Health? Trauma? (physical, mental, emotional)
Father - During Pregnancy
General Health? Cigarettes? if yes, how much? Alcohol? if yes, how much? Emotional Health?
Please describe your child's birth and if there were any complications
Was your child breast-fed after birth?
If yes, for how long?
Aside from water, what was the first liquid introduced to your child other than breast milk?
Did your child have colic? if yes, at what age?
What solid foods were started prior to six months of age?
Food # of months old Reaction
What additional foods were introduced from 6 months of age to 9 months of age?
Food # of months old Reaction
Immunizations/Vaccinations
Immunization Date Any Adverse Reaction? if yes what?
Surgeries/ Accidents/ Trauma
Surgeries/ Accidents/ Trauma Date Effect

New Patient Intake Form – Child

Health Concern	Onset Date	Diagnosis made by	Degree of concern	Treatment to date

Date	Event	Treatment	Precentage of Recovery

General health prior?	Health During Pregnancy?	Cigarettes? if yes, how much	Alcohol? if yes, how much	Emotional Health?	Trauma? (physical, mental, emotional)

General Health?	Cigarettes? if yes, how much?	Alcohol? if yes, how much?	Emotional Health?