YOUTH INTAKE FORM

Thank you for choosing ForeverYoung!

If you have booked an initial exam with us, please take the time to fill out this form the best you can prior to your appointment day. This helps to keep the clinic running smoothly and your appointment on time!

How did you hear about us?

Patient First Name

Phone

Patient Last Name

Birth Date

Street Address

City

Postal / Zip code

Region/State/Province

Names of Parents

Name of Siblings

Band Member ID (where applicable)

HEALTH CARE PROVIDERS

Family Doctor

Midwife

Doula

OB/GYN

Naturopath

Massage Therapist

Acupuncturist

Other Care Providers

Please any health conditions they have been treated for in the last year

PATIENT SYMPTOMS

Describe their chief complaint

When did it start?

What may have caused it?

What makes their complaint feel worse?

If yes, what time?

If yes, how?

If yes, when?

If yes, how much?

If yes, how?

What makes their complaint feel better?

How does their complaint interfere with the following areas of their life?

Family:

Work/School:

Sports/Hobbies:

BIRTH HISTORY

How many weeks?

If yes, please explain

If yes, how many?

Reason for ultrasound?

If yes, how much?

If yes, how many per day?

If yes, how many?

If yes, why?

If yes, how many?

Please list the reasons for intervention/complications

Birth Weight

Birth Length

APGAR

If no, please explain

CHEMICAL STRESSORS

List any medications your child is currently taking

If yes, for how long?

If yes, what type + what age?

Solid foods at age?

If yes, what?

Any adverse reactions to vaccinations?

If yes, why?

PSYCHOLOGICAL STRESSORS

How many hours of sleep does your child get per night?

How many hours of TV/iPad/Computer does your child watch per day?

If yes, please explain

Age slept through the night (5 hours)?

If yes, for how long?

Activities they're involvedin (sports,clubs)?

If yes, please explain

MEDICAL HISTORY

Date of last accident?

If yes, how many accidents?

Known trauma from accident?

If yes, please explain

If yes, what?

QUALITY OF LIFE

Is there any other information you would like us to know?

Thanks for submitting! We have received it.