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Intake Form
Child´s Name
Age
Birthday
Month
Day
Year
Parent / Guardian Name
Relationship to Child
Email
Phone number
Address
Primary Concerns
Main reason for today's visit (check all that apply)
Eczema
Allergies
Asthma
Other
When did symptoms first begin?
How often do symptoms occur?
Daily
Weekly
Occasionally
Seasonally
Describe what symptoms look or feel like:
Known triggers (foods, environment, stress, etc.):
Medical History
Formally diagnosed?
Yes
No
If yes, by whom?
Family history of eczema, allergies, or asthma?
Yes
No
Details:
Hospitalizations/ER visits for skin or breathing issues?
Yes
No
Details:
Other medical conditions (autoimmune, digestive, etc.):
Vaccinations up-to-date?
Yes
No
Partial
Any reactions?
Current & Past Management
Current medications (include dosage):
Supplements or herbs:
Topical treatments or creams:
Therapies tried (medical, natural, etc.):.
What has helped the most?
What has not helped or worsened symptoms?
Lifestyle & Environment
Typical diet (describe breakfast, lunch, dinner, snacks):
Water intake (cups/day):
Sleep duration (hours/night):
Outdoor play or exercise (hours/day):
Bedtime routine:
Quality of sleep:
Restful
Interrupted
Poor
Screen time (hours/day):
Stressors (school, emotional, family, etc.):
Home environment (pets, mold, smoke, carpet, etc.):
Allergies & Sensitivities
Food allergies or intolerances:
Environmental (pollen, dust, pets, etc.):
Drug allergies or sensitivities:
Goals & Additional Notes
What would you like to accomplish through this health education and lifestyle program?
Parent / Guardian Signature
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