Child's Full Name

Date of Birth

Sex

Parent / Legal Guardian Full Name

Relationship to Child

Email

What brings you in today for your child?

When did this concern begin?

What have you noticed over time?

Anything that seems to improve or worsen the situation?

Pregnancy (anything notable?)

Birth (type, complications, if any)

Early development milestones (anything that stood out?)

Feeding history (breast, bottle, challenges)

Past diagnoses

Hospitalizations or surgeries

Current medications

Supplements

Allergies or sensitivities

Vaccination notes (any complications?)

Sleep

Appetite

Food cravings or aversions

Digestion / stools

Thirst

Energy level

Temperature sensitivity

These questions help me understand your child as a whole person. Please answer in your own words.

How would you describe your child’s temperament?

Fears or anxieties you’ve noticed

Triggers (if any)

Social behavior (with peers, adults)

Recent emotional or behavioral changes

Is there anything else you would like me to know about your child?

Consent and Authorization

I am the parent or legal guardian of the child listed above and consent to homeopathic services.

Parent / Legal Guardian Full Name (Electronic Signature)

Date

Pediatric Intake Form