Pediatric Intake Form Amber Wellness Group, PLLC 1944 NE 45th Ave. Portland, OR 97213 Child's Name(Required) First Gender Identity(Required)MFNBDate of Birth(Required) MM slash DD slash YYYY City(Required) Zip Code(Required) Street Address(Required) Phone (Home)Phone (Work)Phone (Cell)Okay to leave a message?(Required)YesNoWhich number?(Required) Parent/Guardian name(Required) Siblings (names & ages)(Required) How was this child referred to our office?(Required) Your Child’s Other Health Care PractitionersNamePhoneFax Add RemoveWhat is your child’s chief health concern(s)? Add RemoveHave the above condition(s) been diagnosed by a health practitioner?(Required)YesNoIf Yes, when and by whom? Does your child receive well--‐child exams?(Required)YesNoIf Yes, from whom? How would you describe your child’s current overall state of health?(Required)ExcellentGoodFairPoorCHILD’S HEALTH HISTORY (answer only those questions that are appropriate for the child's ageHeallthAllergiesSensitivities (environment/food)Hospitalizations & Surgeries (reasons and dates) Add RemoveAt what age did your child begin:Crawling(Required)Please enter a number from 1 to 5.Teething(Required)Please enter a number from 1 to 5.Sitting(Required)Please enter a number from 1 to 5.Walking(Required)Please enter a number from 1 to 5.Talking(Required)Please enter a number from 1 to 5.Toilet Training(Required)Please enter a number from 1 to 5.Were there any problems or concerns at any of these developmental stages?Please indicate with an [✔️] whether your child has experienced any of the following conditions:(Required) Allergies Bloody urine Chicken pox Cradle cap Easy bleeding Eye infections Frequent urination Hair loss Meningitis Nervousness Physical trauma Scarlet fever Stomach flu Vision problems Learning difficulties Asthma Body/breath odor Colds Croup Easy bruising Fatigue Fungal infections Hearing problems Mood changes Night sweats Rash Seizures Strep throat Vomiting Behavior problems Bed wetting Bronchitis Constipation Diarrhea Eczema Fever Gas Lice Mumps Nose bleeds Rheumatic fever Sleeping problems Tonsillitis Coordination problem Eating problems Bladder infections Burning urine Cough Ear infections Emotional trauma Fractures Growing pains Measles Nausea Pneumonia Rubella Sore throat Unusual fears Whooping cough Other If other, please describe: Is there any condition from which you feel your child has never been well since?(Required) IMMUNIZATION HISTORY Please check with an [X] the vaccinations your child has received. If you don’t know if you’ve had one, place a question mark beside it.Diphtheria, Pertussis, Tetanus(Required) Polio(Required) Haemophilus influenza B(Required) Influenza(Required) Meningococcal(Required) Measles, Mumps, Rubella(Required) Varicella(Required) Hepatitis B(Required) Pneumococcal(Required) Other Any adverse reactions following vaccination?(Required) Fever Joint pain Loss of appetite Excessive crying Limping Vomiting Pain/Swelling Mood changes Insomnia Behavior Changes Rash Other If other, please describe MEDICATION HISTORY Please list all over--the--counter and prescription medications & supplements:(Required)Medication/SupplementDoseReason of use Add RemoveFAMILY HISTORYClick HERE to download the file. Once completed, please save and see link to the right to upload it for our review.Please upload your family history(Required)Accepted file types: xlsx, csv, Max. file size: 32 MB.Was this child adopted?(Required)YesNoPRENATAL HISTORY What age was mother at child’s conception?(Required)What age was mother at child’s conception?(Required)Mother's health at conception(Required) Excellet Good Poor Father's health at conception(Required) Excellet Good Poor Was your child conceived naturally?(Required)YesNoWas there any difficulty conceiving this child(Required)YesNoAny fertility interventions?(Required)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: How was the mother’s physical and emotional health during postpartum/recovery?(Required)LABOR & DELIVERYDuration of pregnancy (weeks):(Required)Duration of labor (hours):(Required)Location of labor & delivery(Required)HomeBirthing 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 weight(Required)Birth Lenght(Required)Any difficulties or complications soon after birth? Check all that applies.(Required) Jaundice Poor feeding Respiratory distress Anemia Convulsion Infection(s) Birth defects Colic Other If other, please describe NUTRITIONAL HISTORYWas your child breastfed?(Required)YesNoIf yes for how many months?Any difficulties with breastfeeding(Required)YesNoIf 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?(Required)YesNoFood Cravings?(Required)YesNoAny dietary restrictions?(Required)YesNoIf yes, please explain: Number of bowel movement daily?(Required)Any difficulties?(Required)YesNoPlease list the solid foods introduced prior to 12 months of age, and any reactions noted:FOODAGE OF INTRODUCTIONRESPONSE/REACTION Add RemovePlease 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?(Required)YesNoNumber of hours of sleep nightly?(Required)Naps?(Required)YesNoBad dreams or nightmares?(Required)YesNoHave you observed any of the following during your child’s sleep? Check all that applies.(Required) Sleepwalking Shouting Teeth grinding Talking Moaning Perspiration Laughing Twitching Other Have you observed any of the following during your child’s sleep? Check all that applies.(Required) Sleepwalking Shouting Teeth grinding Talking Moaning Perspiration Laughing Twitching Other If other, please describe: SOCIAL/PSYCHOLOGICAL HISTORYHow would you describe your child’s temperament?How does your child interact with others?Please indicate any emotional traumas your child has experienced:How does your child handle stress?How does your child have any unusual habits?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:(Required)How many hours weekly does your child Watch TV(Required)How many hours weekly does your child Read Books(Required)Any behavioral or learning problems?(Required)YesNoHow is your child’s performance in daycare/school?(Required)Is there anything else you would like to add that may be important regarding your child’s health?(Required)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
