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New Patient Intake Form – Child
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How would you describe your child's general state of health?
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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
Nutritional Summary
Please check the foods your child eat regularly
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breads, Grains, Pasta, Cereal
Fruit
Vegetables
Water
Does your child react to any foods? if so, what is the reaction?
Family Health History
Paternal or Maternal Grandfather
Arthritis
Asthma
Digestive Issues
Diabetes
Respiratory Problems
Thyroid Issues
Weight Concerns
Paternal or Maternal Grandmother
Arthritis
Asthma
Digestive Issues
Diabetes
Respiratory Problems
Thyroid Issues
Weight Concerns
Mother
Arthritis
Asthma
Digestive Issues
Diabetes
Respiratory Problems
Thyroid Issues
Weight Concerns
Father
Arthritis
Asthma
Digestive Issues
Diabetes
Respiratory Problems
Thyroid Issues
Weight Concerns
Siblings
Arthritis
Asthma
Digestive Issues
Diabetes
Respiratory Problems
Thyroid Issues
Weight Concerns
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New Patient Intake Form – Adult
New Patient Intake Form – Child
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We have moved!
Our new address is 69 Kempster Ave.
Ottawa, ON K2B 6M2
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