Get Pediatric Intake Form

Filling out the Pediatric Intake Form online is an essential step in ensuring your child's healthcare needs are effectively communicated. This guide provides a clear and supportive approach to help you navigate each section of the form with confidence.

Follow the steps to complete the Pediatric Intake Form online:

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the patient information. Fill in the child's name, date of birth, and parent or guardian’s name along with contact details such as home phone, cell phone, address, and email address.
3. Indicate whether your child has previously been checked by a doctor of chiropractic and provide the details if applicable. Answer the question regarding if x-rays were taken.
4. In the prenatal history section, answer questions regarding the child's adoption status and any complications during pregnancy. Include a response about smoking or alcohol consumption, as well as any medications taken.
5. Proceed to fill out the birth history. Indicate if ultrasounds were performed, the place of birth, type of birth, and whether pain medications were used during labor. Provide any details on birth trauma if applicable.
6. In the newborn trauma section, record the APGAR score and provide information about any physical conditions such as a misshaped skull or purple markings on the face.
7. Detail your child's feeding history by indicating whether you breastfed and if there are any food allergies. Include information regarding vaccinations and any reactions experienced.
8. Inquire about your child’s surgical history, use of antibiotics, and any current medications or vitamins.
9. For children aged 0-4, address any occurred incidents like falls or reactions to vaccines. For children aged 5-12, list any relevant health problems such as pains, learning difficulties, or activities they participate in.
10. Finally, complete the authorization to treat a minor section. Fill in your name, the child's name, and add your signature to grant permission for treatment.
11. Once all fields are carefully filled out, save your changes. You may then download, print, or share the form as needed.

Take the next step in your child's healthcare by completing the Pediatric Intake Form online today.