Child Intake Form (6-14 years)

Patient's Name *
Patient's Name
Parent Phone *
Parent Phone
Patient's DOB *
Patient's DOB
Name of person completing the form. *
Name of person completing the form.
Please check if the child has had any of the following: *
Please check if the child has/had any of the following trauma: *
Please check if anyone in your family has or ever had any of the following conditions: *
Do you wear contacts or glasses? *
Do you have blurred vision? *
Do you ever get headaches when you read? *
Do you find it hard to concentrate? *
Do you feel stressed out? *
Has your child been immunized? *
Have you noticed a reaction to any of the shots? *
Has your child been diagnosed with Attention Deficit Disorder or Hyperactivity? *
Is there a smoker in the household? *