New Child Client Intake Form - Well of Life Center for Holistic Healthcare

NEW CLIENTS

New Child Client Paperwork

Thank you for

Scheduling Your Child ‘s Appointment

Thank you for scheduling your child’s first appointment. Please complete and submit this form at least 24 hours prior to your consultion. For any other appointment types, new client paperwork will be emailed to you. Please understand the importance of keeping your appointments. We do have a 24 hour cancellation policy that is strictly enforced.

This form should not be completed until after you schedule your initial appointment with our Client Advocate Team. Please schedule an appointment here prior to filling out this form.

PLEASE NOTE: This is the form for children under 18. For adults over 18, please use this form.

Please enable JavaScript in your browser to complete this form.

CHILD/CLIENT'S INFORMATION:

Name:

Date of birth:

Gender:

Male
Female

Current Height:

Current Weight:

Name of Parent/Guardian #1:

Name of Parent/Guardian #2:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Main Phone Number:

Main Contact Person:

Email:

Current school:

Daycare
Public School
Private School
Homeschool

Please describe child’s current symptoms:

What would you like to accomplish/gain from this consultation?

CHILD/CLIENT’S BIRTH INFORMATION:

Birth Weight:

Birth Length:

Child’s place in birth/pregnancy order:

Place/Country of Birth:

If born out of this country, age moved to America:

Mother’s health prior to/during pregnancy. Check all that apply:

Difficulty conceiving
Birth control prior to pregnancy
Received vaccine(s) during pregnancy
Amalgam fillings in teeth during pregnancy (existing or new)
Severe morning sickness/nausea
History of postpartum depression with previous pregnancy
Emotional trauma/turmoil during pregnancy (marriage, family, work stress)

Miscarriage(s):

If so, how many (include dates)?

Child(ren) with other health challenges:

If yes, please explain:

Taking medications during pregnancy:

If yes, list names:

Illness, accident, injury during pregnancy:

If yes, please explain:

Fertility treatments:

if so, please specify how many rounds and dates, and if child was conceived using these methods:

IUI:

Clomid/fertility medications:

IVF:

Surgery to restore fertility:

Donor egg or sperm:

Surrogate:

CHILD/CLIENT’S VACCINE HISTORY:

Has your child ever received any vaccinations?

Please include date of vaccine(s), number in series:

Vitamin K:

Hepatitis B:

Rotavirus:

DTaP:

HiB:

Pneumococcal:

Polio:

Flu:

MMR:

Varicella:

Meningococcal:

HPV:

COVID-19:

CHILD/CLIENT’S DIETARY HISTORY:

Breastfed/nursed:

If yes, for how long:

Check all that apply:

Formula fed
Spitting up/reflux with formula/breast milk
Picky eater
Does not eat/tolerate protein

Age introduced solid foods:

Reaction(s) to foods (check all that apply):

Projectile vomiting
Constipation (more than 1 day without bowel movement)
Diarrhea
Skin rashes/eczema/psoriasis/cradle cap

if so, what reaction(s) to which foods:

Describe typical dietary intake:

CHILD/CLIENT’S HEALTH HISTORY AND CHALLENGES:

Age started to crawl:

Age started to walk:

Age of first tooth:

Age of first words:

Please list any treatments for health challenges:

Tethered oral ties (tongue, lip, buccal):

If so, was it released and at what age?

Allergies: specify allergens, type (anaphylactic, IgE, etc.)

Please describe any current or past diagnoses not listed (including injuries):

Please list any surgeries your child has received (include dates):

Additional notes:

Agreement and Release of Liability:

Please click HERE to read our Liability Release Form and Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of Agreement and Release of Liability.

Website

NEW CLIENTS

New Child Client Paperwork

Thank you for

Scheduling Your Child ‘s Appointment

CHILD/CLIENT'S INFORMATION:

CHILD/CLIENT’S BIRTH INFORMATION:

CHILD/CLIENT’S VACCINE HISTORY:

CHILD/CLIENT’S DIETARY HISTORY:

CHILD/CLIENT’S HEALTH HISTORY AND CHALLENGES:

Contact Us

Hours

Well of Life Center for Holistic Healthcare

Pin It on Pinterest