Child Intake Form (0-12 years)
Please fill out this form before your child's appointment with me. I look forward to working with your family!
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Today's Date
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Child's Full Name
Child's Date of Birth
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Child's Gender
Mailing Address
Parent/Guardian Email Address
Would you like to receive information, including clinic news, events, and health tips, by email?
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Parent/Guardian Name
Parent/Guardian Phone Number
Parent/Guardian Address
Who Does The Child Live With?
Other Health Care Providers
How did you hear about our clinic?
What are the child's main health concerns?
How would you describe your child's general state of health
Please indicate any serious conditions, illnesses, injuries or hospitalizations along with dates:
Please check any of the following illnesses that your child has had
Does the child have allergies - food, medicine, environment?
List all the child's current prescription medications and supplements
List past prescription medications and amount of time on each drug.
Approximately how many times your child been treated with antibiotics?
Did your child receive routine childhood vaccinations?
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Where there any adverse effects to the vaccines?
Describe the mother’s health at conception
Describe the father's health at conception
Describe the mother’s health during the pregnancy
What was the mother’s age at child’s birth?
Describe the mother’s diet during pregnancy
Who provided prenatal care?
Check any of the following which the mother experienced during pregnancy
Were any of the following used by the mother during pregnancy? Please check all that apply
Length of Pregnancy (weeks)
Length of Labour (hours/minutes)
Weight of child at birth
List any interventions used during the birth (epidural, C-section, forceps, induction, etc.)
Were there any complications with the birth?
Check any of the following that the child experienced shortly after the birth.
How was your infant fed?
Did your child ever experience colic?
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If your child experienced colic how severe was it?
Does your child have any food allergies or intolerances?
Does your child have any dietary restrictions?
Describe your child's health in the first year.
At what age did your child first sit up?
At what age did your child first crawl?
At what age did your child first walk?
At what age did your child first talk?
Describe your child’s sleep pattern.
How would you describe your child’s behaviour and performance in school?
Does your child exercise regularly?
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If yes what type and how often?
How much screen time does your child have per day?
What are your child’s favourite activities?
Are there animals in the home?
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Do you know of any toxins or other hazards the child is regularly exposed to?
Check if a close relative (parent, sibling) has had any of the following
Do either of the parents have a chronic illness?
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Please Explain Chronic Illness
Is there anything else that you feel is important that has not yet been covered?
All information collected by this office, remains in this office. Files are placed in a locked cabinet and can only be accessed by Dr. Joanna Thiessen, ND and her personal staff. All information contained in the practice including telephone conversations, correspondence and files are privileged information and cannot be released, copied or discussed without the prior written consent of the patient. Staff are aware of personal identifying information only. They pull and file records as required. *
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