Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
PATIENT INTAKE FORM - CHILD
NAME: ________________________________________________________________
DATE OF BIRTH: __________ AGE: _______ MALE [ ] FEMALE [ ]
NAME OF PARENTS OR GUARDIANS: ___________________________________
ADDRESS: _____________________________________________________________
______________________________________________ POSTAL CODE: _________
HOME PHONE #: ___________________ WORK PHONE #: ___________________
PLACE OF BIRTH: ______________________________________________________
DAYCARE / SCHOOL ATTENDING: _______________________________________
PHONE #: ___________________________
FAMILY PHYSICIAN: ____________________________________________________
PHONE #: ______________________________
CHIEF HEALTH CONCERNS (IN ORDER OF IMPORTANCE):
1.
2.
3.
4.
5.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
SOURCE OF REFERRAL: _________________________________________________
PLEASE STATE WHY YOU HAVE CHOSEN NATUROPATHIC MEDICINE FOR YOUR
CHILD: ____________________________________________________________________________
_____________________________________________________________________________________
HEALTH HISTORY:
HEALTH OF:
MOTHER AT CONCEPTION:
FATHER AT CONCEPTION:
MOTHER THROUGHOUT PREGNANCY
CHILD AT BIRTH
CHILD'S FIRST YEAR OF LIFE
EXC. GOOD FAIR POOR
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
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DETAILS OF PREGNANCY:
PRESCRIPTION DRUGS, SUPPLEMENTS, HOMEOPATHIC REMEDIES, VITAMINS, AND OVER
THE COUNTER MEDICATIONS OF MOTHER DURING
PREGNANCY:________________________________________________________________________
___________________________________________________________
DIET DURING PREGNANCY:_____________________________________________
_____________________________________________________________________________________
___________________________________________________________
1
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
EMOTIONAL STATE OF MOTHER DURING PREGNANCY: ___________________
________________________________________________________________________
WERE ANY OF THE FOLLOWING USED DURING PREGNANCY:
AMOUNT AND FREQUENCY
ALCOHOL
[ ]
________________________________________________
TOBACCO
[ ]
________________________________________________
DRUGS
[ ]
________________________________________________
DETAILS OF BIRTH:
NATURAL
[ ]
C-SECTION [ ]
INDUCED
[ ]
BREECH
[ ]
PREMATURE [ ]
OVERDUE
[ ]
EPIDURAL
[ ]
FORCEPS
[ ]
HOSPITAL
[ ]
HOME BIRTH [ ]
MIDWIFE
[ ]
NAME OF DELIVERER: ______________________ BIRTH WEIGHT: __________
ANY OTHER PERTINENT INFORMATION REGARDING CHILD'S BIRTH:
_____________________________________________________________________________________
___________________________________________________________
BREASTFED?
YES [ ]
NO [ ]
IF YES, HOW LONG? ____________________________________________________
FORMULAS OR TYPE OF MILK USED: ____________________________________
FOODS INTRODUCED:
BEFORE 6 MONTHS: ____________________________________________________
6-12 MONTHS: __________________________________________________________
________________________________________________________________________
HAS YOUR CHILD SUFFERED ANY OF THE FOLLOWING:
DATES AND TREATMENT
JAUNDICE
[ ]
____________________________________
COLIC
[ ]
____________________________________
INFANT ANEMIA
[ ]
____________________________________
TONSILLITIS
[ ]
____________________________________
EAR INFECTIONS
[ ]
____________________________________
SKIN PROBLEMS OR ECZEMA
[ ]
____________________________________
WORMS
[ ]
____________________________________
ALLERGIES
[ ]
____________________________________
RESPIRATORY PROBLEMS
[ ]
____________________________________
DIGESTIVE PROBLEMS
[ ]
____________________________________
HYPERACTIVITY
[ ]
____________________________________
MONONUCLEOSIS
[ ]
____________________________________
CHICKEN POX
[ ]
____________________________________
MEASLES
[ ]
____________________________________
OTHER
[ ]
____________________________________
EXTRA INFORMATION: _________________________________________________
________________________________________________________________________
2
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
HAS YOUR CHILD BEEN VACCINATED?
YES [ ]
NO [ ]
DID YOUR CHILD SUFFER ANY ADVERSE REACTIONS FROM ANY OF THE
VACCINATIONS? ________________________________________________
_____________________________________________________________________________________
___________________________________________________________
PHYSICAL DEVELOPMENT:
AGE
CUT TEETH
___________
SIT UP
___________
WALK
___________
ROLL OVER
CRAWL
FIRST WORD
AGE
___________
___________
___________
CURRENT HEALTH:
ALLERGIES AND / OR INTOLERANCES: _________________________________
________________________________________________________________________
HAS YOUR CHILD HAD AN ALLERGY SCREENING TEST? __________________
DATE: _______________ PERFORMED BY: _________________________________
RESULTS: ______________________________________________________________
TYPICAL DIET OF YOUR CHILD:
BREAKFAST
LUNCH
________________
________________
________________
________________
________________
________________
________________
________________
DINNER
________________
________________
________________
________________
SNACKS
__________________
__________________
__________________
__________________
DO THEY EXPERIENCE ANY SYMPTOMS AFTER EATING CERTAIN FOODS?
_____________________________________________________________________________________
___________________________________________________________
HAS YOUR CHILD EVER TAKEN ANTIBIOTICS? __________________________
DATE
ANTIBIOTIC
REASON
_________
_______________
__________________________________________
_________
_______________
__________________________________________
_________
_______________
__________________________________________
_________
_______________
__________________________________________
OTHER MEDICATIONS (INCLUDE OVER THE COUNTER DRUGS, HERBS, HOMEOPATHIC
REMEDIES, VITAMINS, AND PRESCRIPTION DRUGS)
DATE
MEDS
REASON
_________
_______________
__________________________________________
_________
_______________
__________________________________________
_________
_______________
__________________________________________
_________
_______________
__________________________________________
_________
_______________
__________________________________________
_________
_______________
__________________________________________
3
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
ADVERSE REACTIONS TO MEDICATIONS? PLEASE DESCRIBE. _____________
_____________________________________________________________________________________
___________________________________________________________
ACCIDENTS, INJURIES, SURGERIES AND HOSPITALIZATIONS:
_____________________________________________________________________________________
___________________________________________________________
HOW WOULD YOU BEST DESCRIBE YOUR CHILD?
INTROVERTED
[ ]
EXTROVERTED
[ ]
SHY
[ ]
AGGRESSIVE
[ ]
PASSIVE
[ ]
ACTIVE
[ ]
ATHLETIC
[ ]
CREATIVE
[ ]
LEADER
[ ]
FOLLOWER [ ]
SERIOUS
[ ]
LAID BACK [ ]
EMOTIONAL
[ ]
PHYSICAL
[ ]
HAPPY
[ ]
SAD
[ ]
OTHER ________________________________________________________________
DESCRIBE YOUR CHILD'S PERFORMANCE AT SCHOOL: __________________
________________________________________________________________________
TYPE OF HOME HEATING: _________________________ AGE OF HOME: _____
RUGS [ ]
HARDWOOD [ ]
LINOLEUM [ ]
DOES ANYONE LIVING IN THE HOUSE SMOKE? _________ AMOUNT: ________
DESCRIBE THE EMOTIONAL CLIMATE OF YOUR HOME:
_____________________________________________________________________________________
_____________
HOBBIES OF CHILD:
_____________________________________________________________________________________
_____________
FAMILY HISTORY (health issues)
Mother:
Father:
Siblings:
Maternal grandparents:
Paternal grandparents:
Please circle any family history of following conditions:
Cancer, Heart Disease, Diabetes, Multiple Sclerosis, Parkinson's, Alzheimer's, Rheumatoid arthritis,
Mental Illness, Asthma, Allergies, Psoriasis, Eczema, Alcoholism, Glaucoma, High Blood Pressure,
Kidney Disease, Thyroid Disease, Inflammatory Bowel Disease
PLEASE LIST CHILDREN IN YOUR FAMILY:
NAME
AGE
SEX
_____________________________________________________
_____________________________________________________
4
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
Child REVIEW OF SYSTEMS
* Please write C for current issues and P for past issues*
Vitality
Low stamina
Fatigue
Depression
Poor sleep
Poor concentration
Poor memory
Anxiety
Bad temper
Easily stressed
Skin
Dryness
Itching
Bumps on back of arms
Pimples / Acne
Cracking
Eczema
Psoriasis
Easy bruising
Poor wound healing
Musculoskeletal
Weakness
Stiffness
Aches
Twitching
Cramps
Joint pain
Head
Migraines
Tension Headaches
Head trauma
Eyes
Burning
Dryness
Itching
Double vision
Blurring
Sensitive to light
Failing vision
Conjunctivitis / Styes
Ears
Loss of hearing
Ringing in the ears
Wax build-up
Ear Pain
Ear Infections
Nose
Itching
Loss of Smell
Discharge
Sneezing
Sinusitis
Polyps
Nosebleeds
Mouth / Lips
Cold sores
Lips cracking
Cankers
Jaw clicks
Jaw pain
Bad breath
Peculiar taste in mouth
Teeth
Cavities
Sensitive to hot / cold
Bleeding gums
Grinding teeth
Respiration
Hay fever
Asthma
Coughing
Bronchitis
Shortness of breath
Frequent sore throats
Frequent colds / cough
Circulation / Blood
Cold hands / feet
Edema (swelling)
Low blood pressure
High blood pressure
Anemia
Fainting
Fingernails
White spots on nails
Nails won’t grow
Splitting, Peeling,
Cracking
Gastrointestinal
Heartburn
Indigestion
Belching
Flatulence
Bloating after eating
Fatigue after eating
Nausea / vomiting
Constipation
Diarrhea
Alternating diarrhea and
constipation
Irritable if late for a meal
Emotional on empty
stomach
Wake at night hungry
Excess thirst
Urination
Increased Frequency
Blood in urine
Painful urination
Night urination
Incontinence
Neurological
Seizures / convulsions
Muscle weakness
Numbness / tingling
Memory loss
Involuntary movement
Loss of balance
Speech problems
5
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
Dr. Lynette Panych, ND
Acknowledgment and Consent For Naturopathic Medicine:
Naturopathic doctors provide primary and complementary health care by focusing on the
scientific use of natural therapies to support and stimulate healing processes. Naturopathic
doctors use standard medical diagnostic tools (physical exam, fitness testing, health history,
laboratory and imaging studies, etc.) Therapies used in naturopathic practice are:
* Botanical Medicine
* Homeopathic Medicine
* Traditional Chinese Medicine/Acupuncture
* Clinical Nutrition
* Lifestyle/Fitness Counseling
*Vitamin Injections
A confidential record will be kept of your health consults and will not be released without your
consent or unless directed by law. I permit Dr. Panych, NDto use her discretion in consulting
with other professionals (who are also bound by provincial privacy laws) regarding my health in
order to provide me with optimal medical care. (You may look at your file at any time and can
request a copy by paying a minimal fee.)
I voluntarily consent to the diagnostic and therapeutic procedures mentioned above.
I understand that there are health risks involved with Naturopathic Medicine services and I hereby
release Dr. Lynette Panych, ND from any claims, demands and causes of action arising from my
voluntary participation in these services.
I understand that failure to follow naturopathic prescriptions could undermine the expected
results. Naturopathic Doctors reserve the right to determine which cases fall outside his/her
scope of practice, in which event an appropriate referral will be made.
I allow communication via Email as it saves resources and response times. Dr. Panych, ND
makes every attempt to prevent computer / internet criminal activity. I understand the inherent
risk involved with computer and internet use and release Dr. Panych, ND from any liability.
All fees for services and supplements are payable at the time of the appointment. There is a fee
for completing insurance forms, letter writing, and telephone consultations of greater than 5
minutes. Please give 24 hour notice for appointment cancellations and acknowledge that
failure to do so will result in a cancellation fee for the full cost of the appointment booked.
I have read, understood, and acknowledge the above statements. I intend this consent form to
cover the entire course of treatment/training. I am free to withdraw my consent and or terminate
treatment at any time.
_______________________
DATE
_______________________________
PRINTED NAME
_________________
SIGNATURE
2