Belleville_Pediatric

Date of Initial Appointment

Who referred you to BIHC

Reasons for Visit

Confidential Client Information

Name

Address

CITY

PROVINCE

POSTAL CODE

(H) Phone #

Format: (000) 000-0000.

(W) Phone #

Format: (000) 000-0000.

(C) Phone #

Format: (000) 000-0000.

Email

example@example.com

Age

Date of Birth

Pronouns

Other

Preferred Method of Contact (Select one)

I agree to receive future email communications from B.I.H.C. containing news, updates and promotions. You may withdraw your consent at any time.

Family Physician

Physician's Phone Number

Format: (000) 000-0000.

Emergency Contact Name

Emergency Contact relationship to you

Emergency Contact Phone #

Format: (000) 000-0000.

Medications

List any and all medications/supplements you are currently taking.

Medication Name #1

Dosage/Frequency #1

Condition it Treats #1

Medication Name #2

Dosage/Frequency #2

Condition it Treats #2

Medication Name #3

Dosage/Frequency #3

Condition it Treats #3

Medication Name #4

Dosage/Frequency #4

Condition it Treats #4

Medication Name #5

Dosage/Frequency #5

Condition it Treats #5

Medication Name #6

Dosage/Frequency #6

Condition it Treats #6

Client History

Please answer all that apply:

Was your child full term (39 weeks+)? If not, please indicate how many weeks they were born at:

Select one:

Any complications with birth? (Vacuum, forceps, shoulder dystocia, etc) If yes, what?

Does your child have a preference to turn their head in one direction? If so, what side do they turn their head to?

Is your child breastfed, bottle fed or both? Please elaborate and include bottle type:

Has your child had a procedure to correct a tongue and/or lip tie? If so, when did this occur and who did the procedure?

Did/Does your child use a pacifier or suck their thumb/fingers?

Do you have any concerns about your child’s development? If so, please elaborate:

Does your child suffer from chronic ear infections? If so, please elaborate:

Does your child surfer from allergies? If so, please list:

Do you have any concerns about your child hitting their developmental milestones?

Do you have a family history of scoliosis or hip dysplasia?

Has your child experienced any of the following? Check/Circle and elaborate as needed:

How long does it take baby to eat?

How often does your baby eat?

Do you have any of the following symptoms? (If applicable) Please check/circle and elaborate as needed:

Nipple pain when baby first latches on (rate on scale of 1 to 10)

Baby prefers feeding on one breast over the other? If so, WHICH SIDE?

Health History

Present involvement in other health care (Select all that apply)

Have you received any medical and/or drug treatment for this complaint?

Please provide details:

Surgery #1

Date #1

Surgery #2

Date #2

Have you had any of the following tests for the condition(s) for which you are presently referred?

Please check all health conditions that apply:

List of allergies (if applicable):

Type of Diabetes (if applicable):

Weeks pregnant (if applicable):