Pediatric Intake Paperwork
Child's Legal Name
First Name
Last Name
Today's Date
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Month
-
Day
Year
Date
Child's Date of Birth:
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Month
-
Day
Year
Date
Legal Guardian's Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
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Area Code
Phone Number
Work Phone
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Area Code
Phone Number
Home Phone
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Area Code
Phone Number
Email
example@example.com
Preferred Method of Contact
Child's Social Security Number
Your Occupation
Your Employer
Whom to contact in case of emergency? (please list relation and best contact number)
Personal Medical History
Preferred pharmacy (name and address):
Child's pediatrician (name and address):
Please list complaints for your child in order of priority:
Please list any allergies and reactions to medicines or foods your child has:
Please list pharmaceutical medicines your child takes, along with the dose:
Medication name
Dose
Frequency (how often you take medication)
1
2
3
4
Please list any health supplements your child takes, along with the dose:
Health Supplement name
Dose
Frequency (how often you take medication)
1
2
3
4
Please list any major illnesses, accidents or hospitalizations your child has experienced including dates:
Date of your child's last physical exam:
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Month
-
Day
Year
Date
Any abnormal results?
Date of your child's last blood work:
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Month
-
Day
Year
Date
Any abnormal results?
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Family Medical History
Do any members of your child’s immediate family suffer from any of the following health conditions?
Heart Disease/High Cholesterol
Diabetes
High Blood Pressure:
Cancer (Please describe under "Additional Information")
Alcoholism/Drug Addiction
Mental Health Disorder (Please describe under "Additional Information")
Other serious health conditions (Please describe under "Additional Information")
Additional Information
Does your child have any problems with any of the following body systems?
EENT: (head, ears, eyes, nose, throat)
Endocrine: (thyroid or another hormone imbalance)
Nervous system: (dizziness, imbalance, slow thinking, poor memory)
Respiratory: (allergies, asthma, chronic cough)
Skin: (psoriasis, eczema, acne)
Cardiovascular: (heart palpitations, chest pain, cold hands and feet, varicose veins)
Digestive: (GERD, heartburn, nausea, constipation, diarrhea, gas, bloating)
Musculoskeletal: (chronic back or limb pain)
Psychological: (anxiety, depression)
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Lifestyle
Please provide examples of typical meals:
Please Provide examples of typical meals
Breakfast
Lunch
Dinner
Snacks
How much water does your child drink in a day?
Does your child exercise? If so, please list types and amount per week:
Are there any problems with sleep? How many hours does your child typically sleep in a night?
Please list your health goals for your child in order of priority:
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Terms of Consent for Care
I...
First Name
Last Name
Signature of Legal Guardian
Clear
Date
-
Month
-
Day
Year
Date
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New England Naturopathic Health Policies
Please initial in the following boxes:
I understand that payment of consultation fees, lab fees, supplements and any other services are due at the time of service.
I understand that phone consultations and phone lab reviews with Dr. Marinaro/Dr. Froman will be billed at the same rate as an in-office visit
I understand that I may message Dr. Marinaro’s/Dr. Froman’s support staff through Charm. Email is not an acceptable communication format due to confidentiality concerns.
I understand that any supplements purchased at NENH or via Health Wave (per NENH request) cannot be returned once opened.
I understand that if I am more than ten minutes late for an appointment. I may not be seen and may be assessed a cancellation fee.
I understand that should I miss an appointment or cancel with less than a twenty-four hours’ notice, I will be assessed a cancellation fee.
I understand it is my responsibility to ensure insurance coverage for both office visits and labs ordered by a Naturopathic Doctor. Please refer to the Insurance Benefits Verification form for additional information.
I understand that Naturopathic doctors in the state of Maine serve as specialists and not primary care doctors. For this reason, I understand that it is my responsibility to have a PCP, or to be actively looking to establish care with a PCP, prior to establishing care at New England Naturopathic Health.
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