Pediatric Intake Form

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Child information

Basic details about the patient.

Child's full name *

Date of birth *

Your relationship to the child *

Mother Father Grandparent Foster parent Other relative Self (patient)

Where is the child living now?

Times moved in the last year

Does anyone else care for the child?

Who?

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Health history

Allergies, immunizations, hospitalizations, and current health status.

How would you rate this child's health?

Excellent Good Fair Poor

Any medication allergies?

Which medications?

Has the child received immunizations?

Which ones and where?

Has the child ever been hospitalized?

When, where, and why?

Has the child received care elsewhere?

What kind of care?

Any concerns about behavior or development?

Main concerns about your child

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Home & safety

Seatbelt use, home safety, firearms, and tobacco exposure.

How often does your child use a seatbelt / carseat?

Never Rarely Sometimes Often Always

Does your child ride a bicycle?

How often does he/she use a helmet?

Do you feel you live in a safe place?

In the past year, have you felt threatened in your home?

Has a partner or family member pushed, punched, kicked, or hit you?

Guns in the home?

Is the gun locked up?

Does anyone in your household smoke?

Do you currently smoke cigarettes?

Cigarettes per day

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Caregiver information

About you — the parent or guardian completing this form.

Your age

Marital status

Highest education level completed

How often in the last week have you felt depressed?

0 days 1–2 days 3–4 days 5–7 days

In the past year, have you felt sad or depressed for 2+ weeks?

Have you had 2+ years feeling depressed most days?

Would you like info about parenting programs or parent hotlines?

Would you like info about birth control or family planning?

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Help & support

Your support system and family activities.

Who can you count on to be dependable? (initials & relationship)

How satisfied are you with their support?

Who accepts you totally, including your best and worst points?

Who do you feel truly loves you deeply?

How strong are your family's religious beliefs?

Religious affiliation (if any)

How often do you read bedtime stories to your child?

How often does your family eat meals together?

What does your family do together for fun?

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Review & submit

Please review your answers before submitting.

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Intake form submitted

Your form has been received by Rising Star Pediatrics. Dr. Marie will review it before your child's first visit.

Your submission is encrypted and will be automatically deleted after 14 days. No patient information was sent via email.