Pediatric Constipation Intake Form
Please complete this form to share the child's constipation history, current symptoms, diet, routines, and relevant medical background before the visit.
Patient & Caregiver Information
Child's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Caregiver/Parent Name
*
Relationship to Child
*
Please Select
Mother
Father
Guardian
Grandparent
Other
Best Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Constipation History & Current Symptoms
Main reason for visit
*
How long constipation has been occurring
*
Stool frequency
*
Several times per day
Daily
Every 2-3 days
Once a week or less
Unsure
Stool consistency/appearance
*
Please Select
Hard pellets
Firm stools
Large stools
Painful stools
Loose stools
Unsure
Associated symptoms
Abdominal pain
Bloating
Straining
Blood with stool
Stool withholding
Accidents/soiling
Pain with bowel movements
Loss of appetite
Unsure
Treatments already tried
Diet, Fluids, and Routine
Daily fluid intake (approx. cups per day)
Diet pattern and fiber/fruit/vegetable intake
Toileting habits / potty-training status
Not potty trained
Potty training in progress
Trained and uses toilet independently
Trained but needs help
Other
Recent changes in routine, stress, travel, or illness
Medical Background & Visit Details
Current medications or supplements
Known allergies
Relevant medical history
Preferred appointment date and time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: