Child Intake Form (Birth-5 years)

Patient's Name *
Patient's Name
Patient's DOB *
Patient's DOB
Parent Phone *
Parent Phone
Name of person completing the form. *
Name of person completing the form.
Which of the following did you experience during pregnancy? *
Did you fall or have a motor vehicle accident while pregnant? *
Did you use any of the following while pregnant? *
Which of the following applies to your labor and delivery? *
What was your child's head position? *
Was the baby...? *
Was intensive care required? *
Please check if your child has/had any of the following trauma *
Please check if your child has had any of the following: *
Is your child a good eater? *
Does your child have any food allergies? *
Does your child take any supplements? *
Does your child sleep well? *
Does your child have frequent temper tantrums? *
Does your child cry a lot? *
Do you think your child has good balance? Do you think your child has good balance? Do you have any concern about your child's health? *
Does your child go to daycare? *
Is there a smoker in your household? *
Did you choose to have your child vaccinated? *
Did your child ever have a reaction to an immunization? *