Pediatric Intake uestionnaire - Practical Healing
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1/27/2021 Pediatric Intake Questionnaire
Pediatric Intake uestionnaire
Please set aside some time to thoughtfully fill out our intake form to help us to best care for
your child. On average this form takes around 45-60 minutes to complete. If you have any
issues completing the online form and prefer a printable PDF version to complete and scan
back to us, please let us know.
NOTE: We recommend you complete this form in one sitting so you don't lose any progress,
however, if you find you cannot finish in one sitting - use the NEXT SECTION buttons at the
bottom of each section until you reach the end and click SUBMIT. This will send us what you
have completed, and display a clickable link to come back and finish later.
* Required
1. Email address *
2. Patient Name:
3. Name of individual completing this form, and relationship to the patient.
4. Parent/Guardian phone number:
5. Parent/Guardian address:
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 1/331/27/2021 Pediatric Intake Questionnaire
6. Today's date:
Example: January 7, 2019
7. How did your hear about our practice?
Mark only one oval.
IFM Website
Referral from another medical provider
Referral from friend/family member
Social media
Website
Other:
Please answer the following questions about your child:
8. Age:
9. Date of birth:
Example: January 7, 2019
10. Address (if different from parent/guardian)
11. Phone number (if different from parent/guardian)
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12. Emergency contact (please list name, relation, and phone numbers)
13. Who is your child's primary care provider (list name and date of last visit):
14. Have your child seen a functional medicine or similar practitioner before? If so, please list name
and what type of practitioner.
15. What do you hope to achieve for your child by partnering with Practical Healing?
16. Is there anything you would prefer we do not discuss in front of your child and/or anything you
want me to know that you would not feel comfortable bringing up during the visit?
If you are bringing your child for care at Practical Healing due to health concerns please fill
out this section to the best of your ability. If you do not have any current concerns about
Current your child's health, and are seeking care for preventative reasons only, feel free to skip to
Concerns the next section!
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 3/331/27/2021 Pediatric Intake Questionnaire
17. CURRENT concerns (please list symptom/health problem, and when the concern began:
18. Do you have any behavioral or emotional concerns for your child?
19. Did something trigger a change in your child's health?
20. What seems to improve your child's symptoms?
21. What seems to make your child's symptoms worse?
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22. What are your child's biggest struggles day to day?
Please answer the following questions to the best of your ability. It is ok to leave
Medical questions blank if you are unsure.
History
23. Allergies (list allergy and reaction):
24. Prescription Medications (name, dose):
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25. Supplements (name, dose):
FAMILY HISTORY:
26. Background (check all that apply):
Check all that apply.
African American
Hispanic
Mediterranean
Asian
Native American
Caucasian
Northern European
Other:
27. Please list your child's immediate family members, age, and any medical problems. (Ex: Mother,
age 37, diabetes and hypothyroidism). If deceased, please list cause of death if known.
BIRTH/CHILDHOOD HISTORY:
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28. Regarding your child's birth, check all that apply:
Check all that apply.
Cesarean Section
Vaginal Delivery
Term
Premature
Forceps or vacuum assisted delivery
29. Were there any complications surrounding your child's birth?Did any maternal illnesses or
stressful events occur during pregnancy?
30. Was your child breast-fed? If yes, how long?
31. Was your child formula fed? If yes, list what type of formula and for how long:
32. Is your child up-to-date on vaccinations?
Mark only one oval.
Yes
No
Some but not all CDC recommended vaccines
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33. Does your child get a flu vaccine annually?
Mark only one oval.
Yes
No
Sometimes
34. Has your child had any of the following childhood illnesses:
Check all that apply.
Chicken Pox
Measles
Mumps
Epstein-barr virus ("mono")
Recurrent ear infections
Recurrent strep throat
Rheumatic fever
Other:
35. Have there been any concerns about your child's developmental milestones?
ILLNESSES/CONDITIONS
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36. Check any illness/condition that your child currently has or has had in the past:
Check all that apply.
Current Past
Irritable bowel syndrome
GERD (reflux)
Crohn's disease
Ulcerative Colitis
Peptic ulcer disease
Celiac disease
Cold sores
Bronchitis
Asthma
Pneumonia
Sinusitis
Sleep Apnea
Kidney Stones
Kidney Disease
Kidney Infection
Autoimmune conditions
Lyme Disease
Yeast infections
Urinary tract infections
Abnormal pap smear
Sexually transmitted disease
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 9/331/27/2021 Pediatric Intake Questionnaire
Testicular mass/lump
Hernia
Type 1 Diabetes
Type 2 Diabetes
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Metabolic syndrome/insulin resistance
Eating disorder
Hypoglycemia
Environmental allergies
Immune deficiency
Liver disease
Chronic pain
Tendonitis
Eczema
Psoriasis
Vitiligo
Acne
Heart Conditions
Heart murmur
Hypertension (high blood pressure)
Stroke
Irregular pulse
High cholesterol or triglycerides
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 10/331/27/2021 Pediatric Intake Questionnaire
Murmur
Epilepsy/seizures
ADD/ADHD
Headaches
Tension Headaches
Migraines
Depression
Anxiety
Mood swings
Bipolar disorder
Autism
Neurologic Conditions
37. Please describe any other medical problems not listed above:
38. Does your child wear glasses or contacts?
39. Does your child have any difficulty hearing and/or use hearing aids?
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DIAGNOSTIC TESTING
If your child has had any of the following diagnostic tests please list the date and known findings.
40. CT scan
41. Colonoscopy
42. EKG
43. MRI
44. Upper Endoscopy (EGD)
45. Chest X-ray
46. Other X-ray
47. Barium swallow test
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INJURIES/SURGERIES/HOSPITALIZATIONS
48. Has your child had any major injuries? If yes, please list below with dates. (Ex - broken bones,
head injury, car accident etc.)
49. Please list any surgeries and date of surgery (Ex - appendectomy, dental surgery, gallbladder,
hernia, hysterectomy, tonsillectomy, heart surgery etc)
50. Please list any hospitalizations, include reason and date.
DENTAL HISTORY:
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51. Check if your child has had any of the following:
Check all that apply.
Silver/mercury fillings
Gold fillings
Root canals
Dental Implants
Caps/crowns
Other:
52. Does your child brush regularly?
Mark only one oval.
Yes
No
53. Does your child floss regularly?
Mark only one oval.
Yes
No
54. Has your child started puberty?
Mark only one oval.
Yes
No
Maybe
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55. Female child, Age at first period:
56. Female child: Date of last menstrual period:
Example: January 7, 2019
57. Any concerns related to puberty or sexual health:
Please answer the following questions to the best of your
ENVIRONMENTAL/EXPOSURE ability.
HISTORY
58. Is your child sensitive to smells?
Mark only one oval.
Yes
No
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59. Regarding your child's home environment, or any other environment the child is in frequently -
is there known exposure to any of the following? Check all that apply:
Check all that apply.
Mold
Water leaks
Renovations
Harsh chemicals (solvents, cleaning chemicals, glues, gas, acids etc)
Electromagnetic radiation
Damp environments
Old paint
Smoke or second hand smoke
Pesticides/herbicides
Heavy metals (lead, mercury, etc)
Paints
Other:
60. Has your child had any significant exposure to any harmful chemicals? If yes, list chemical
name, length of exposure and date.
61. Are there pets in the child's home? If yes, Please list what type, how many, and if they live
inside, outside or both.
62. Are there farm animals at the child's home, if yes please list what animals:
63. List any foreign travel and dates:
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64. Has your child ever had an illness while traveling?
65. Has your child been diagnosed with COVID-19? If yes, when?
66. Has anyone in close contact with your child been diagnosed with COVID-19? If yes, do you
believe your child was exposed? Please list when the exposure occurred.
67. Has your child ever been bitten by a tick? If yes, list date. Also describe any treatment or if the
child had a subsequent illness.
68. Has your child been given/taken any of the following regularly or for a long period of time?
Check all that apply.
NSAIDS (Advil, Aleve, Aspirin, Motrin, Ibuprofen, Naproxen, etc.)
Acetaminophen (Tylenol)
Acid Blocking drugs (Omeprazole, Prilosec, Nexium, Zantac etc)
69. How many times has your child taken antibiotics?
Mark only one oval.
Less than 5 times
Greater than 5 times
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70. Has your child ever been on long term antibiotics? If yes, please describe timeframe and reason:
71. Has your child taken steroid medications? If yes, please describe:
Please check all that apply, be sure to indicate if the symptom is current or
Your Child's Symptom in the past 6 months.
Checklist
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 18/331/27/2021 Pediatric Intake Questionnaire
72. Symptoms
Check all that apply.
Current Past 6 months
Cold hands and feet
Cold intolerance
Fatigue
Weight gain
Fever
Flushing
Heat intolerance
Night sweats
Low body temperature
Distorted sense of smell
Distorted sense of taste
Ear fullness
Ear ringing/buzzing
Eye crusting
Eye pain
Eye redness
Headache
Hearing loss
Migraines
Sensitivity to loud noises
Vision problems
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 19/331/27/2021 Pediatric Intake Questionnaire
Back pain
Muscle cramps
Foot cramps
Joint pain
Joint redness
Joint stiffness
Joint deformity
Muscle pain
Muscle spasm
Muscle twitching
Muscle weakness
Neck muscle spasm
Auditory hallucinations
Visual hallucinations
Fainting
Depressed mood
Difficulty concentrating
Balance issues
Difficulty with speech
Memory concerns
Difficulty with judgement
Dizziness (room spinning)
Lightheadedness
Irritability
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 20/331/27/2021 Pediatric Intake Questionnaire
Fearfulness
Numbness
Weakness
Panick attacks
Paranoia
Seizures
Suicidal thoughts
Mood swings
Tingling
Tremor
Chest pain
Shortness of breath
Palpitations
Swollen ankles/feet
Urinary Hesitancy
Urinary frequency
Urinary urgency
Pain/burning with urination
Urinary leaking/incontinence
Anal spasms
Bad teeth
Bloating of lower abdomen
Bloating of upper abdomen
Bloating after meals
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 21/331/27/2021 Pediatric Intake Questionnaire
Blood in stools
Belching
Canker sores
Cold sores
Constipation
Cracking at corner of lips
Chewing difficulty
Diarrhea
Difficulty swallowing
Dry mouth
Gas/Flatulence
Anal fissures
Heartburn
Hemorrhoids
Jaundice
Abdominal pain
Mucus in stools
Nausea
Periodontal disease
Sore tongue
Strong stool odor
Undigested food in stools
Vomiting
Can't gain weight
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 22/331/27/2021 Pediatric Intake Questionnaire
Can't lose weight
Poor appetitie
Bad breath
Bad odor in nose
Pelvic cramping
Breast tenderness
Heavy periods
Irregular periods
Dry cough
Productive cough
Hoarseness
Nasal stuffiness
Nose bleeds
Post nasal drip
Sinus fullness
Sinus infections
Snoring
Sore throat
Wheezing
Brittle Nails
Ridges to nails
Toenail fungus
Fingernail fungus
White spots/lines on nails
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 23/331/27/2021 Pediatric Intake Questionnaire
Enlarged lymph nodes
Dry skin
Dandruff
Acne
Bumps on back of upper arms
Ears get red
Easy bruising
Eczema
Hives
Jock itch
Rash
Red face
Sensitive to insect bites
Sensitive to poison ivy/oak
Strong body odor
Itchy skin
Itchy anus
Itchy ears
Itchy roof of mouth
Itchy throat
Please answer the following questions regarding your child's day-to-day life:
Lifestyle Review
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NUTRITION
73. Please describe a typical breakfast, lunch, dinner and snacks for your child:
74. Does your child have aversions to certain foods? Please describe:
75. Does your child have any symptoms related to foods? These can be true allergies, OR
sensitivities/intolerances. Please describe:
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76. Does y0ur child seem to have adverse reactions to any of the following?
Check all that apply.
MSG
Artificial sweeteners
Garlic/onion
Cheese
Citrus foods
Chocolate
Sulfite containing foods (dried fruit, salad bars)
Leftovers
Preservatives
Food colorings
Other:
77. Does skipping a meal negatively affect your child?
Mark only one oval.
Yes
No
78. How many meals does your child eat out per week?
Mark only one oval.
0-1 meals per week
1-3 meals per week
3-5 meals per week
>5 meals per week
79. How often do you prepare meals at home?
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 26/331/27/2021 Pediatric Intake Questionnaire
80. Do you cook from scratch?
Mark only one oval.
Yes
No
81. How would you categorize your experience with cooking?
Mark only one oval.
Beginner
Intermediate
Advanced
82. Does your child have a history of previous or current eating disorder or disordered eating? If so,
please describe:
83. Does your child drink caffeinated beverages? If so, list what type and how many cups per day of
each.
84. To your knowledge, has your child ever used alcohol, tobacco products or recreational drugs?
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 27/331/27/2021 Pediatric Intake Questionnaire
MOVEMENT
85. How many minutes of sustained physical activity does your child get per day?
Mark only one oval.
None
30 minutes
60 minutes
Greater than 60 minutes
86. Is there anything that limits movement for your child?
87. What activities involving movement does your child enjoy? (Ex: Dancing, playing basketball,
etc)
SLEEP
88. How many hours of sleep does your child get on average?
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 28/331/27/2021 Pediatric Intake Questionnaire
89. What time does your child typically go to bed?
Example: 8:30 AM
90. Please answer the following about your child:
Mark only one oval per row.
Yes No
Difficulty falling asleep
Difficulty staying asleep
Rested in the morning
Snoring
Has nightmares
Has had a sleep study
Diagnosed with sleep apnea
91. Does your child use any sleeping aids? (medications, supplements, TV/noise machine etc)
STRESS
92. Do you feel your child is under an excessive amount of stress?
Mark only one oval.
Yes
No
https://docs.google.com/forms/d/1rBV5NpVski69aoiAA6rMnmOPmThOyjDzd0aowC63aGA/edit 29/331/27/2021 Pediatric Intake Questionnaire
93. Has your child ever been in counseling for any reason?
94. Has your child been witness to or experienced any potentially traumatic events that you are
aware of?
95. Are there any significant stressors we should know about?
Please answer the following:
Stress Relief, Hobbies, Homelife & Education:
96. Do you use relaxation techniques with your child? If yes, list:
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97. Does your child have resources for emotional support? If yes, check all that apply:
Check all that apply.
Family
Friends
Religion/Spirituality
Pets
Other:
98. Does your family identify with a religion or spiritual practice? If yes, describe here:
99. What hobbies or activities does your child enjoy?
100. Does your child live with both biological parents?
101. Who does your child live with? Please list all household members (ex: Mom, grandma, 7 year
old sister)
102. Does your child share a room with anyone?
103. How many times has the child moved to a different home in their lifetime?
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EDUCATION
104. What grade is your child in?
105. Which school does your child attend?
106. Does your child have an IEP or 504 plan?
Mark only one oval.
Yes
No
Other:
107. To help us work through a timeline with you and your child, please list any significant life
events and years. (Ex: Birth, moves, family events, marriage, divorce, siblings born, illnesses,
major surgeries, traumas, school transitions etc)
Almost done!
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108. How willing are you to follow a prescribed nutrition and lifestyle plan for your child?
Mark only one oval.
1 2 3 4 5
Not Willing Very Willing
109. Is there anything you feel may make it difficult for you to make any recommended lifestyle
changes?
110. How much ongoing support do you think you will need/want from our team? Rate from 1
(minimal) to 5 (extensive).
Mark only one oval.
1 2 3 4 5
We want you to know how much we appreciate the time and effort you've put into completing
this form. We look forward to reviewing this information with you during your child's New
Thank Patient Visit. If you have any questions before your child's visit feel free to reach out to our
you! office. Make sure to click SUBMIT below!
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