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Child
Intake Form
What’s your child's first name?
What’s your email address?
What’s your child's last name?
What’s your phone number?
Street Address
City
Postal / Zip code
Street Address Line 2
Region/State/Province
Country
Health + Medical History
Current Weight
Birthday
Gender
Referred by:
Child's Height
Personal Health History
Please include your Diagnosis, Date of Onset, Current or Past + Description
Please include your Family Member + Illness(es)
Please include your Hospitalization/Surgeries, Date + Reason(s)
Please list any allergies or sensitivities that you have (food, environmental, etc.) + your Reactions
Was this child born vaginally or via C-section?
vaginal
C-section
I'm not sure
Was this child breast-fed or formula-fed?
Breastfed
Formula
A mix of both
I'm not sure
Female Child: Have they started their menstrual cycle yet?
Not cycling yet
Cycling (regular)
Cycling (irregular)
Currently on Birth Control
Other
Female Child: have they ever taken birth control?
No
Yes
Have you ever taken antibiotics?
No
Yes
Have they had any vaccinations?
No
Yes
Supplements/vitamins
List all the supplements you're currently taking including vitamins, herbs, minerals. Please include the Brand Name, Dose + Frequency, Start Date + Reason for taking it
Medications
List all medications you're currently taking. Please include Brand Name, Dose + Frequency, Start Date + Reason for taking.
Ranking current health concerns
List your current health concerns from most important/worst and rank from 5 (most intense) to 0 (not intense). Please include how often it bothers you + how long it has been present for.
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