Pediatric Web Intake Form (Birth - 5 Years): Printable Form: Children's form (pdf) If you are a new patient we ask that you fill out an intake form. Pediatric Intake Form ( Birth - 5 Years)    Dr. Erika Kneeland, ND     Patient's name: Date of first visit: Age:     Date of Birth:     Gender: female male Mother's name: Father's name: Address: City: Province: Postal code: Phone # (home): Parents # (work): Parents e-mail:   How did you hear about our Clinic?  Name of Dr.'s Office/Hospital/Clinic where your child's health records are kept: Reason for referral or presenting problems: MEDICATIONS   Now Past     Now Past Aspirin   Antibiotics Tylenol   Anti-histamine Decongestant   Other Ibuprofin   please list: Allergies to medicines: MEDICAL HISTORY (check all that apply) Chicken Pox Scarlet fever Tonsillitis, approx. no. Measles Pneumonia Ear Infections, no.       Mumps Frequent colds Other (please list) Rubella Rheumatic fever     Has your child had any of the following tests?   when where results Electroencephalogram Psychological evaluation Hearing Speech/Language Injuries/Surgeries/Hospitalizations (please list): IMMUNIZATIONS Measles Polio MMR Smallpox Diphtheria Mumps DPT Tetanus Influenza Other (please list) Any adverse reactions? NO YES   If yes, please explain:   FAMILY HISTORY Heart Disease Diabetes Birth defects Cancer Hypertension Arthritis Mental illness Allergies     PRENATAL HISTORY Previous pregnancies by natural mother, miscarriages, or complications? Mother's age at child's birth? Mother's health during pregnancy? (Check all that apply) Bleeding Physical or emotional trauma Nausea Cigarettes, alcohol, drug consumption Illnesses Medications Hypertension Thyroid problems Diabetes     BIRTH HISTORY Term: Full Premature Late    Weight at birth: Length of labor:    Complications? Did your child have any of the following problems shortly after birth? Birth defects Birth injuries Blue baby Cerebral palsy Seizures Jaundice Colic Fever Rashes Other, explain:   Child's sleep patterns (first year):  Food intolerances (if any):  Feeding: Breast fed? YES NO        How long?       Formula: YES NO milk soy Age began solids:    Which foods?   Age began:  Sitting:   Crawling:   Walking:   Talking:     SYMPTOMS (Mark Y if current, P significant past symptom) Hives   Burning of urine   Bloody urine Eczema   Frequent urination   Cries easily Bleeding gums   Heart murmur   Nervous Nose bleeds   Vomiting spells   Sleep problems Acne   Anemia   Night sweats High fevers   Stomach aches   Sensitive to light Chronic rash   Jaundice   Body/breath odor Hearing loss   Easy bruising   Motion/car sickness Diarrhea   Flat feet   No appetite Sore throats   Constipation   Nightmares Headaches   Gas   Canker sores Frequent Colds   Bleeding tendency   Unusual fears Wheezing   Joint pains   Excessive fatigue Cough   Dizzy spells   Hair loss   DIET Please describe your child's typical daily diet: Breakfast: Lunch: Dinner:  Snacks: To Drink:     Extra Notes: Thank you.  I look forward to helping your child in any way I can.   Your first consultation will be for 1 hour. This will ensure adequate time to begin a treatment program for you and to address the initial reasons for your visit. Treatment protocols vary from individual to individual even if two people express very similar symptoms. For information on fees for your appointments, please refer to the costs and coverage page.

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#2-204 North Island Highway,  Courtenay, BC V9N-3P1
Phone: (250) 334-0655  Fax: (250) 334-9418