Pediatric Screening/Intake Form

Pediatric Intake Form
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Parent/Guardian DOB*

MonthDayYear
Date
Relationship*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Insurance*
Insurance Policy #*
Insurance Group #*
Primary Care Physician *
Pharmacy of choice and compounding pharmacy*
How did you hear about us
Best way to communicate
May your provider discuss private medical information with you via email or voicemail*

YesNo
Fathers Name

First NameLast Name
Mothers Name

First NameLast Name
Please list your top main concerns/symptoms*
What do you hope to achieve in your visit with us?*
If you had a magic wand and could help your child in three ways, what would they be?*
When was the last time you felt your child was well?*
Did something trigger your child's change in health?*
Is there anything that makes your child feel worse?*
Is there anything that makes your child feel better?*
Is the child adopted

YesNo
Are the parents

MarriedDivorcedSeperated
Please list any others living in the child's home and their relationship
BIRTH HISTORY
Birth Weight
Apgar
Was the delivery

VaginalC-Section
Was the child

TermEarlyLate
Did the child have any problems right after birth?
Did the mother have any problems during pregnancy
During pregnancy, did the mother

smokedrink
Did the baby go home with the mother from the hospital

YesNo
CHILD HISTORY
Please List any Current Therapies

Development

	Yes	No
Are you concerned about your childs physical development
Did your child hit the proper milestones
Are you concerned about your childs mental development
Are you concerned about your childs attention span
Are you concerned about your childs behavior at school/grades?

Please explain any YES answers:
Family History (Patients mother, father, sister, brother, aunt, uncle, grandfather, grandmother)

AllergiesAsthmaDeafnessTuberculosisHeart Disease (onset prior to age 50)High Blood PressureStrokeDiabetesHigh CholesterolAnemia, leukemia or free bleedingLiver DiseaseConvulsions or seizuresMigrainesADHD/Learning disabilityMental Illness/suicideMental retardationImmune deficiency/HIVCancer
Does your child have or has he/she ever had

Frequent ear infectionsProblems with ears or hearingAllergiesProblem with eyes or visionAsthma, wheezingHeart palpitationsAnemiaBlood transfusionsAbdominal painRecurrent vomitingChronic DiarrheaConstipation/Other digestive issuesBed-wetting after age 5(For Girls) Started her menstrual period(For Girls) Are there any problems with her periodsAny chronic or recurring skin problemsColicThroat infectionsPersistent diaper rashesRecurrent coldsThrushBehavioral problemsDental amalgam fillings
Please explain selected answers

Gasstrointestinal*

	Current	Past	None
Irritable Bowel Syndrome
Inflammatory Bowel Disease
Gastritis or Peptic Ulcer Disease
GERD (reflux)
Celiac Disease

Cardiovascular*

	Current	Past	None
Heart Disease
Elevated Cholesterol
Hypertension (high blood pressure)

Metabolic/Endocrine*

	Current	Past	None
Diabetes
Hypoglycemia
Metabolic syndrome
Hypothyroidism (low thyroid)
Hyperthyroidism (high thyroid)
Endocrine Problems
Weight gain
Weight loss
Frequent weight fluctuations
Bulimia
Anorexia
Binge eating disorder
Night eating syndrome
Eating disorder (not-specific)

Cancer*

	Current	Past	None
Any type of cancer

Genital and Urinary Systems*

	Current	Past	None
Kidney stones
Urinary tract infections
Yeast infections

Musculoskeletal/Pain*

	Current	Past	None
Muscle spasms/stiffness/joint pain
Fibromyalgia
Chronic Pain

Inflammatory/Autoimmune*

	Current	Past	None
Autoimmune Disease
Rheumatoid Arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor immune function (frequent infections)
Food allergies
Environmental allergies
Multiple chemical sensitivities

Respiratory Diseases*

	Current	Past	None
Frequent ear infections
Frequent upper respiratory infections
Asthma
Chromic sinusitis
Bronchitis
Sleep Apnea

Skin Diseases*

	Current	Past	None
Eczema
Psoriasis
Acne

Neurologic/Mood*

	Current	Past	None
Depression
Anxiety
Bipolar disorder
Headaches
Migraines
ADD/ADHD
Sensory integrative disorder
Autism
Mild cognitive impairment
Seizures

Previous Evaluations

Full Physical ExamPsychological EvaluationSpeech and Language EvaluationsGenetic EvaluationNeurological EvaluationGastroenterology EvaluationCeliac/Gluten TestingAllergy EvaluationNutritional EvaluationAuditory EvaluationVision EvaluationOsteopathicAcupuncturePhysical TherapyOccupational TherapySensory Integration TherapyLanguage ClassesHomeopathicNaturpathicCraniosacralChiropracticMRICT ScanUpper EndoscopyUpper GI SeriesUltrasound
Blood Type*

ABABORh+Unknown
Medication List
Drug Allergies
Surgeries/Hospitalizations
Any Diagnosis from other providers
Vaccines

Sleep History

	Yes	No
Does your child fall asleep easily
Does your child stay asleep through the night
Does your child have nightmares
Does your child wake up feeling refreshed

Digestive History
Does your child have any digestive issues? If no, please skip to the next section

YesNo
How often does your child have a bowel movement
What is your childs stool like? (check all that apply)

Well-formedSmall, Hard piecesFoul-smellingMucousGreasy, floatsPainfulLooseBloodyWateryThin and long
Does you child have heartburn or reflux

YesNo
Does you child have frequent gas or belly bloating

YesNo
Does your child have abdominal pain

YesNo
Any other comments or concerns?
Environmental History
Are you concerned about environmental allergies or toxins. If NO, please skip to next section

YesNo
Water

WellCityPurification system
Does your home have alot of dust

YesNo
Is your child exposed to cigarette smoke

YesNo
Has your child traveled out of the country, if yes, where?
Any other comments of concerns:
Diet
Are you concerned with your child's diet?

YesNo
Was your child

BreastfedBottle-fed
At what age was solid foods introduced
Do you suspect food allergies or intolerance?

YesNo
If Yes, please explain
Please select your childs current diet

No restrictionsGluten FreeCasein FreeYeast Free or Mold FreeSalicylate FreeIgG reactive foods avoidanceLow PhenolicsOrganicHigh Protein/Low CarbSpecific Carb Diet

	Yes	No
Does your child eat sugar
Does your child eat fast food
Does your child eat food with artificial colors/flavorings or preservations
Does your child eat artificial sweeteners
Does your child drink soda
Does your child eat foods that are pre-packaged

If yes to any above, what kind and how ofter?
Any other comments or concerns:
Please list everything your child eats in a typical day (give 3 examples of each)
Breakfast
Lunch
Evening
Snacks
Do you currently or have you ever had a problem with weight, eating or food (if yes, please explain)
Who prepares your child's meals?
How often does your child eat out?
ADD/ADHD
Are you concerned with you child's behavior or suspect ADD/ADHD. If NO, please skip to next section

YesNo

	Yes	No
Often fails to give close attention to details or makes careless mistakes in school work, work or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish school work, or chores
Often has difficulty organizing tasks and activities
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
Often loses things necessary for tasks or activities
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or in other situations
Often runs about or climbs excessively
Often has difficulty playing or engaging in leisure activities quietly
Often talks excessively
Often is "on the go" or acts as if "driven by a motor"
Often blurts out answers before questions have been completed
Often as difficulty awaiting turn
Often interrupts or intrudes

Please explain YES answers

Learning Problems

	Yes	No
Recognizing unfamiliar words when reading
Comprehending the meaning of what he/she reads
Spelling problems
Problems expressing ideas in writing
Problems expressing ideas orally
Memory problems
Handwriting problems
Problems organizing work or homework
Problems completing homework in a timely manner
Excessive absences from school

Please Explain YES answers
Generalized Anxiety Disorder
Does you child have excessive anxiety and worry occurring more often than not in the last 6 months. If NO, please skip to the next section

YesNo
Anxiety and worry are associated with at least 3 of the following symptoms

Restlessness or feeling keyed up or on edgeBeing easily fatiguedTrouble with concentrationIrritabilityMuscle TensionTrouble falling asleep or staying asleep or restless sleep
Major Depressive Disorder
Are you concerned with your child's mood or have you seen a behavior change in your child? If NO, please skip this section

YesNo

	Yes	No
Depressed or irritable mood most of the day, nearly every day, as indicated by complaints of feeling sad or appears to be sad
Diminished interest or pleasure in all, or almost all activities most of the day, nearly every day
Significant weight loss or weight gain when not dieting
Trouble falling asleep or staying asleep or excessive sleeping
Agitated or lethargic nearly every day
Fatigue or loss of energy nearly every day
Feelings of worthlessness
Diminished ability to concentrate or cannot make a decision nearly every day
Repeated thoughts of death, repeated suicidal thoughts without a specific plan or with a plan

Please explain YES answers
Gluten sensitivity symptoms questionaire
Does your child have any of these problems?

Tired and exhaustedUncomfortable tummyBloating and gas troublesGastric reflux or heartburnDiarrhea or constipationWeight issuesNot growing wellEating problemsLack of energyrun-downRunny nose or sinus problemsChronic iron deficiency anemiaGrowing painsDermatitis, eczema, itchy or bad skinHeadachesFeeling depressed or moodyPoor sleephyperactivityADHDAutismMental Health Problems
Any other comments or concern not covered that we should be aware about?
Robinhood Integrative Health, (RIH) believes “Health As It Should Be” involves the integration of all aspects of one’s life by treating the total patient and not merely the symptoms. Some components of integrative care that we utilize to promote optimal health and well being currently do not have the FDA’s stamp of approval. However, at RIH we make sure that there are scientific studies which support all practices we employ.

We utilize the following tools among others; proper nutrition, tailored supplements, bioidentical hormones, exercise and pharmaceutical medications when needed. We will also offer various courses, programs and lectures which will benefit you as a patient. Additionally, as a service and time savings convenience for our patients, we offer various supplements and products that have been carefully chosen in terms of quality and cost effectiveness available for purchase at our office.

Presently, some tests that make medical sense may not always be reimbursed by insurance companies. Also, certain medications particularly those that come from a compounding pharmacy, may not be covered by insurance. We are sensitive to the fact that you will have to cover these expenses. With every decision or recommendation that RIH makes, your cost obligations are considered. Ultimately we feel any expense you bear today will be an investment in a future that produces a lifetime of optimal health and well being.

If at any time you prefer a traditional medical approach please inform us and we will happily comply.

If you have any disappointments please talk to our office manager
CREDIT CARD AUTHORIZATION
Thank you for choosing Robinhood Integrative Health as your healthcare provider. As per our office policy and in an effort to keep health care costs as low as possible, we require you keep a credit card on file. This is to your advantage, since health care costs in general can be substantial. By using a credit card, you have the ability to spread the cost over time, making payments to your credit card company, rather than paying the cost all at once. Of course, you can always use and alternative method of payment at check-out if you desire.

This form authorizes Robinhood Integrative Health to charge your expenses to the card on file unless an alternative method of payment is presented. This includes payments at the check-out window, payments over the phone, payments for purchases in our store and payments that are 90 days in arrears. (You will have received three billing statements).

Please note: Only one credit card is held on file at a time and it is the last card that you have used.

If you have any questions, please do not hesitate to call us.
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Office Policies

Insurance:

Insurances we do accept are BCBS (all plans except Blue Value and Blue Local), Aetna (except for the Limited Network of Wake Health, Duke Health, Cone Health), Cigna, Medcost (except for the Limited Network of Wake Exclusive Network), and Coventry.

We have opted out of Medicare and we do not accept Medicaid or certain Tricare policies. We have elected to not have the government dictate how we should care for patients and therefore are unable to accept these policies.

We are out of Network with United Health Care which means you would pay all costs out of pocket and then you can file with UHC insurance directly.

For patients who are not covered by insurance or as a result of the above policies, we offer a private contract for a fee of $360 per hour or $6 per minute. The average charge for the first visit is $600-$960. This is NOT reimbursable by Medicare or Medicaid.

Our Practice:

We are problem focused so will not be taking over your primary care. We suggest that you maintain your PCP for routine medical care and sick visits. Due to demand, we are unable to take on every patient with interest in our practice. We take on cases that include symptoms, diseases and challenges that we feel we can most effectively treat based upon our strengths and are unable to take on new patients who are primarily seeking wellness or primary care with an integrative approach.

Financial Requirements:

All patients are required to join our patient portal for $60 a year and the payment for that is due on your first visit. The charge will recur every year on the anniversary of your first visit.

Every patient is required to keep a credit or debit card on file. Our credit card processor is nested in a banking center, so its security greatly exceeds a typical medical office. Outstanding balances will be automatically charged to the card on file at 90 days. Integrative care, such as ours is uncommon and most integrative practices are cash only.

We are a hybrid practice, accepting insurances but also acknowledging that there are out of pocket expenses. We are happy to discuss expenses with you prior to treatment. If you have a high deductible plan, you can utilize our cash prices for our labs run through LabCorp, otherwise the labs will be filed through Insurance. There are many different tests, that are not available at your PCP's office and not covered by Insurance. We consider them medically necessary for optimal treatment of our patients, but Insurance often does not. These tests do qualify for coverage for HSA's and FSA's, however.

There is a $7.50 Form Fee and a $36 Return Check Fee.
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PERMISSION TO COMMUNICATE
So that we may provide you with better quality of care, you have the option of providing us with a list of family and friends with whom we may discuss your health information. You are not required to provide a list but it is helpful. If you do not want us discussing any information with anyone other than yourself please right “None” on the line below. By listing the names below an signing this form I give consent to Robinhood Integrative Health to discuss health information with the people listed below who assist with my care. If I do not want certain information discussed, I have listed it below.

*THIS FORM WILL STAY IN EFFECT UNTIL YOU NOTIFY ANY CHANGES.
Do NOT discuss information about:*
Please list name, number and relationship of whom we may share information with*
I give Robinhood Integrative Health permission to leave Normal lab/test results on my answering machine/voicemail.*

YesNo
Signature*

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Pediatric Intake Form