Pediatric Intake Form Amber Wellness Group, 1944 NE 45th Ave. Portland, OR 97213 Child's Name(Required) First Gender Identity(Required)MFNBDate of Birth(Required) MM slash DD slash YYYY Street Address(Required) City(Required) Zip Code(Required) Phone (Home)Phone (Work)Phone (Cell)Okay to leave a message?YesNoParent/Guardian name(Required) Siblings (names & ages) How was this child referred to our office? Your Child’s Other Health Care PractitionersNamePhoneFax Add RemoveDoes your child receive well--‐child exams?YesNoIf Yes, from whom? What is your child’s chief health concern(s)? Add RemoveHow would you describe your child’s current overall state of health?ExcellentGoodFairPoorCHILD’S HEALTH HISTORY (answer only those questions that are appropriate for the child's ageHeallthAllergiesSensitivities (environment/food)Hospitalizations & Surgeries (reasons and dates) Add RemoveAny problems or concerns with growth and development?Please indicate with an [✔️] whether your child has experienced any of the following conditions: Allergies Chicken pox Easy bleeding Eye infections Meningitis Nervousness Scarlet fever Vision problems Learning difficulties Asthma Croup Easy bruising Fatigue Fungal infections Hearing problems Mood changes Rash Seizures Strep throat Vomiting Behavior problems Bed wetting Bronchitis Constipation Diarrhea Eczema Sleeping problems Tonsillitis Coordination problem Eating problems Bladder infections Ear infections, frequent Measles Pneumonia Rubella Other If other, please describe: Immune History Diphtheria, Pertussis, Tetanus Polio Haemophilus influenza B Influenza Meningococcal Measles, Mumps, Rubella Varicella Hepatitis B Pneumococcal Any adverse reactions following vaccination? MEDICATION HISTORY Please list all over--the--counter and prescription medications & supplements:Medication/SupplementDoseReason of use Add RemoveFamily History Heart disease Auto immune disease Hypertension Mental illness Celiac Cancer Diabetes Food allergies Other Was this child adopted?YesNoPRENATAL HISTORY What age was mother at child’s conception?Was your child conceived naturally?YesNoWas there any difficulty conceiving this childYesNoAny fertility interventions?YesNoIf yes, explain: List any illnesses, medications or exposures to toxins during pregnancy:Medications (over the counter & prescriptions), supplements and herbs taken during the pregnancy:Please indicate with an [✔️] any health conditions mother experienced during the pregnancy. Check all that applies.(Required) Diabetes Edema (swelling) Emotional trauma Fainting Rubella Infection(s) High blood pressure Thyroid Problems Nausea/Vomiting Physical trauma Bleeding Anxiety/Fear Depression Other If other, please describe: LABOR & DELIVERYDuration of pregnancy (weeks):Duration of labor (hours):Location of labor & deliveryHomeBirthing CenterHospitalPlease indicate with an [✔️] which intervention were used during birth. Check all that applies. Induced labor Forceps Vacuum extraction Epidural/Anesthesia Episiotomy Oxytocin/Pitocin Pain Medication Cesarean section Other NEONATAL HISTORY Birth weightBirth LenghtAny difficulties or complications soon after birth? Check all that applies. Jaundice Poor feeding Respiratory distress Anemia Convulsion Infection(s) Birth defects Colic Other If other, please describe NUTRITIONAL HISTORYWas your child breastfed?YesNoIf yes for how many months?Any difficulties with breastfeedingYesNoIf yes, what were the difficulties?What type & brand of infant formula, if any, was used? Age solid foods were introduced: How would you describe your child’s eating habits? Food Aversions?YesNoAny dietary restrictions?YesNoIf yes, please explain: Number of bowel movement daily?Any difficulties?YesNoPlease outline your child’s typical daily food intake:BreakfastLunchDinnerSnacksWater intake (ounces):What source (tap, filtered, distilled, spring)?Other fluids Add RemoveSLEEP HISTORYDoes your child sleep through the night?YesNoNumber of hours of sleep nightly?Naps?YesNoBad dreams or nightmares?YesNoHave you observed any of the following during your child’s sleep? Please explain SOCIAL/PSYCHOLOGICAL HISTORYHow would you describe your child’s temperament?How does your child interact with others?What are your child’s favorite activities?How often does your child exercise?How many hours weekly does your child Play on the computer or video games:How many hours weekly does your child Watch TVHow many hours weekly does your child Read BooksAny behavioral or learning problems?YesNoPlease explain How is your child’s performance in daycare/school?Is there anything else you would like to add that may be important regarding your child’s health?Policies and ConsentsBy voluntarily signing this document, I show that I have been provided the clinic policies and consent to treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Initial each section belowHIPAA Notice of Privacy Practices(Required) I acknowledge that I received a copy of Amber Wellness Group clinic policies, as well as, HIPAA privacy laws and I agree to the use of my medical information for my treatment. Financial Responsibility(Required) I understand that I am responsible for full payment of services and supplements at the time of service. (Those not billing insurance receive a 20% discount on visits) Insurance Billing(Required) I understand that I am responsible for completing the insurance verification form and know that I am responsible for payment for any non-covered services denied by my insurance company. Roles and Responsibilities for Provider and Patient(Required) I understand that my provider will only prescribe medications that they believe are in my best interest and it is my responsibility to keep them informed of any changes or updates in my health or outside medications. Labs Review(Required) I accept that any labs ordered by my provider requires a follow up appointment for review and interpretation to establish an appropriate treatment plan. Prescription Refill Policy(Required) I accept responsibility to call my pharmacy when I need a refill on my pharmaceutical medications, even if I am out of refills. The clinic will respond to all refills within 48 hours of receiving notice from the pharmacy. Supplements(Required) I understand that refills on my supplements should go through the front office to verify availability, or I can use the clinic’s online dispensary through Fullscript. Cancellation Policy(Required) I understand that it is my responsibility to know when my appointment is and that reminders from the clinic are a courtesy. Failure to notify the clinic 48 hours prior to my appointment, for either a cancellation or rescheduling, or missing my appointment entirely will result in a $140 fee E-consult Policy(Required) I understand that the patient portal is where my provider will communicate with me as it is the most secure platform. Any messages that I send that go beyond simple clarification may be subject to an e-consult fee By signing below: I acknowledge that I have been provided ample opportunity to read the HIPAA Notice of Privacy Practices provided by the clinic or that it has been read to me. I understand all of the above and give my oral and written consent to evaluation and treatment. I intend this as a consent form to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment. I agree that I will consult the consent form or call the office for clarification when I have concerns regarding my care at Amber Wellness Group. Printed Name of Patient/Guardian(Required) First Last Signature(Required)Date(Required) MM slash DD slash YYYY
