Online Pediatric Intake Form (0-12yo)





    Postal Code

    Telephone (Home)

    Telephone (Parent's Work)

    Parent's Email



    Date of Birth (mm/dd/yyyy)


    Child Lives With

    Emergency Contact

    Emergency Phone

    Emergency Relation

    How did you hear about our practice?

     I would like to receive our newsletter by email

    Health Concerns

    Please list your health concerns in order of importance

    Vitamins and Supplements

    List all vitamins/minerals/herbal supplements your child currently taking


    List all prescription and non-prescription medications your child is currently taking

    List any major illnesses, injuries and/or surgeries that your child has had and when

    Has your child ever experienced any of the following?

    Vaccinations (please check)

    Did your child experience any adverse effects from vaccinations? If yes, please explain


    Does your child have any medical allergies or sensitivities? Please list:



    Weight (lbs)

    Weight 1 year ago (lbs)

    Family History

    Please put an "L" for living and "D" for deceased, and present age or age at time of death. Indicate if the family member suffered from any disease or conditions such as cancer, high blood pressure, heart attack, stroke or diabetes.




    Maternal Grandmother

    Maternal Grandfather

    Paternal Grandmother

    Paternal Grandfather



    Prenatal Health and History

    Was this child adopted?

    If yes, at what age?

    Mother's age at time of child's birth

    Did the mother receive medical care during the pregnancy?

    Did the mother experience any of the following during pregnancy?

    Please check all that apply

    If other, please explain

    Were any of the following interventions used during pregnancy?

    Please elaborate on what the mother was using

    Did the mother use any of the following during pregnancy?

    Birth History

    Type of birth

    Term length


    If other, please list all interventions

    Were there any complications during delivery (eg. breech)?

    Length of labour (hrs)

    Weight of infant at birth (kg/lbs)

    Did the child experience any of the following at or shortly after birth?

    Health and Development

    At what age did your child first:

    Sit up




    Start teething

    Nutritional History

    How was your infant fed?

    For how long?

    Did your infant experience any reactions to the breast milk or formula?

    What foods were introduced before 6 months? Please list the approximate month and any reactions.

    What foods were introduced between 6 and 12 months? Please list the approximate month and any.

    Typical Food Intake





    To Drink


    I attest that the information provided is true and accurate to the best of my knowledge.

    Signature (Full Name)

    Date (mm/dd/yyyy)


    Naturopathic Doctors minimize the risk of harmful side effects, by supporting the body's own capacity to heal and by using the least invasive procedures for diagnosis and treatment whenever possible. However, even the gentlest therapies have potential for complications. Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease, or in specific patient populations such as pregnant or lactating women, very young children, or patients taking multiple medications. It is very important that you inform your Naturopathic doctor immediately of:

    • Any disease process that you are suffering from

    • If you are on any medication or over the counter drugs

    • If you are pregnant, suspect you are pregnant, actively attempting to become pregnant or you are breast-feeding

    There are some slight health risks to treatment by Naturopathic Medicine. These include but are not limited to:

    • Aggravation of pre-existing symptoms

    • Allergic reactions to supplements or herbs

    • Pain, bruising or injury from acupuncture or blood draws

    • Fainting or puncturing of an organ with acupuncture needles

    I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or when law requires it. I understand that I may look at my medical record at anytime and can request a copy of it or have a report drawn up by paying the appropriate fee.

    I understand that my Naturopathic Doctor will answer any questions that I have to the best of his/her ability. I understand that the results are not guaranteed. I do not expect the Naturopathic Doctor to be able to anticipate and explain all risks and complications. I will rely on the Naturopathic Doctor to exercise judgement during the course of the procedure which they feel at that time is in my best interests, based on the facts then known.

    I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

    If I am unable to make my appointment I must provide advance notification within 48 hours in which case no charge will be applied.

    THIS IS TO ACKNOWLEDGE that I have been informed and I understand that:

    1. Any treatment or advice provided to me as a patient is not mutually exclusive from any treatment or advice that I may now be receiving from another licensed health care provider, or may receive in the future;

    2. I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider qualified to practice in Alberta;

    3. No employee, student or anyone else under the Clinic's direction or control is suggesting or advising me to refrain from seeking or following the directions of another licensed health care provider;

    4. The treatment and therapies rendered or recommended by this Clinic may be different than those usually offered by a medical doctor or other licensed health care provider.

    I DECLARE that I have received a full and complete explanation of the treatment or services that I may receive and hereby authorize and consent to treatment.

    I AGREE to pay my full account at the time of each visit or treatment, including fees for services, cost of supplements and remedies, as well as other applicable fees. I understand that there is a fee for completing insurance forms, letter writing, telephone consultations greater than 10 minutes and emails that take greater than 10 minutes to answer. Notice of 48 hours is required for appointment cancellation, otherwise you will be charged an administrative fee of $35.00.

    Patient's Full Name

    Date of Consent (mm/dd/yyyy)