Intake Form - Pediatric Name * Date Address Street City Prov./State Postal/Zip Code Email * Telephone (Home) Telephone (Work) Telephone (Cell) Age Sex - None -MF Date of Birth Year Year1999200020012002200320042005200620072008200920102011201220132014201520162017 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Parent's Name(s) Your Medical Doctor Other Health Practitioners Involved in Care: Emergency Phone Contact Name Emergency Phone Contact # Does the child have private insurance that covers Naturopathic Medicine? - None -YesNo Insurance Provider Limit of Coverage ($) How did you hear about the clinic? If found online, please let us know the search engine & words typed in to find us. Please list the reasons for this visit in order of importance & how long your child’s had the problem: Please indicate your expectations and what you hope to accomplish with your Naturopathic visit: Symptoms (please select all that apply) Fatigue Weight gain/loss Stiffness Depression Anxiety Excessive anger Excessive fears Weeping Irritability ADD Developmental delays Autism Memory loss/foggy thinking Behavioral problems Restless legs Cold hands/feet Dizziness Seizures Insomnia Numbness/tingling Weakness Skin problems: Headaches Eye problems: Ear problems: Sinus problems: Metal taste Frequent sore throats Heat/cold intolerant Allergies Difficulty breathing: Wheezing Asthma Cough Digestive problems Diarrhea/Constipation Nausea/vomiting Liver problems: Gallbladder problems: Urinary difficulties: Bed wetting Bladder/kidney infection PMS Testicular pain Frequent infections Frequent colds/flus Diabetes Period begins every _____ days (if applicable) Cancer (Please indicate type) Other BIRTH & DEVELOPMENTAL HISTORY Term of Pregnancy - None -Full TermPrematureLate Weight at Birth Length of Labour Mother’s age at child’s birth # of months breast fed Formula - If not breastfed, what kind of formula? Complications - None -YesNo Colic - None -YesNo Birth Injuries - None -YesNo Birth Defects - None -YesNo Blue Baby - None -YesNo Rashes - None -YesNo Jaundice - None -YesNo Cerebral Palsy - None -YesNo Solid food Age Sitting up Age Crawling Age Walking Age Other MOTHER’S HEALTH DURING PREGNANCY Previous pregnancies, miscarriages Bleeding - None -YesNo Nausea - None -YesNo Medications Cigarettes/ drugs - None -YesNo How many/day Alcohol - None -YesNo How Much High blood pressure - None -YesNo Gestational diabetes - None -YesNo Thyroid Problems - None -YesNo Current Medications Current Medication Include medications, vitamins, supplements, herbs, over-the-counter drugs. Allergies Hospitalizations (& year) Diseases in family history Reactions to vaccinations INFORMED CONSENT FOR TREATMENT for Dr. Sean Ceaser, ND TO THE PATIENT’S PARENTS: You have the right, as a parent, to be informed about your child’s condition and the recommended treatments and procedures to be used so that you make an informed decision whether or not to undergo the recommended procedure(s) after knowing the benefits and risks involved. This notice is not meant to alarm you; it is simply to inform you that you may give or withhold your consent to treatment. All information given now or at any point in the future is confidential. It is Naturopathic Physicians Group’s policy to require a medical release form before releasing medical records to anyone other than the patient. If you refuse any specific procedure this will not affect your child from receiving other care or future treatments. I voluntarily request Dr. Ceaser to examine and treat my child and their health conditions. I understand that the course of care therapy may include the use of multiple modalities of Naturopathic medicine including nutritional supplements, injection therapies, intravenous nutrients, chelation, ozone, hyperthermia, and other therapies offered by Dr. Ceaser. I understand that my verbal consent to a specific treatment and my willing participation in my child receiving these therapies after explanation of benefits and risks is sufficient to indicate my consent to have mychild receive treatment. I waive the option of signing a consent to treat for each and every specific procedure at each treatment date. I understand that I am free to pursue other medical opinions and treatments including conventional medical care at any time for my child. I understand that I have the right and the opportunity to ask questions about my child’s condition, discuss naturopathic and conventional options at any time. I understand there may be complications and risks related to the recommended procedure(s) and that I may request additional information regarding complications and risks (side effects) and refuse any specific treatment at any time. I understand that payment is due in full at the time of service. I understand that no warranty or guarantee regarding a promise of cure as a result of care is provided for any condition. Informed Consent * I certify that I have read this form or have had it read to me and that I understand its content and meaning. I have sufficient information to give this informed consent.