Pediatric Sleep Supplement Intake Form
Please complete this form to provide essential information for safe and effective pediatric sleep supplement use.
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 Age
*
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Does your child have any known allergies?
*
No known allergies
Food allergies
Medication allergies
Other (please specify)
List any current medications your child is taking (include supplements and over-the-counter medicines).
*
Which sleep supplement is being considered?
*
Please Select
Melatonin
Magnesium
Herbal supplement (e.g. chamomile, valerian)
Other (please specify)
Intended dosage and frequency for supplement
*
Describe your child's current sleep patterns or concerns (e.g. trouble falling asleep, frequent waking, nightmares, etc.).
*
Does your child have any diagnosed medical conditions (e.g. asthma, epilepsy, developmental disorders)?
*
No diagnosed conditions
Asthma
Epilepsy
Developmental disorder
Other (please specify)
Has your child previously taken this or any other sleep supplement?
*
Yes
No
Is there anything else we should know about your child's health or sleep habits?
Parent/Guardian Signature
*
Submit Intake Form
Submit Intake Form
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