Pediatric Patient Intake Survey
Please complete this form to help us provide the best care for your child. All information is confidential and used solely for medical assessment.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Gender
*
Male
Female
Other
Parent or Guardian Name
*
First Name
Last Name
Parent or Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent or Guardian Email
example@example.com
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does the child have any known allergies?
No known allergies
Food allergies
Medication allergies
Environmental allergies
Other (please specify)
Current Medications (please list all that the child is currently taking)
Medical History
Rows
Yes
No
Asthma
1
2
Diabetes
3
4
Heart condition
5
6
Seizures
7
8
Recent surgery
9
10
Hospitalization in the past year
11
12
Other chronic conditions
13
14
Please rate the severity of your child's current symptoms:
1
2
3
4
5
Has your child received all recommended vaccinations for their age?
Yes
No
Not sure
Briefly describe the reason for today's visit or any current symptoms:
*
Submit Intake Survey
Should be Empty: