BIG SKY INTEGRATIVE HEALTH, PC 8707 N. Jackrabbit Ln. Ste. E Belgrade, MT 59714(406) 388-6676 *Newborn - 5 Yrs Downloadable Form* *6-12 Downloadable Form* Pediatric Intake Form Name * First Name Last Name Today's Date MM DD YYYY Age Date of Birth MM DD YYYY Gender Male Female Father's Name Father's Phone (###) ### #### Mother's Name Mother's Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance Primary Holder's Name Subscriber ID # Group # Primary's DOB MM DD YYYY Primary's Phone (###) ### #### Relationship Primary's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Primary's SSN# How did you hear about the clinic? Name and address of Dr.’s office/hospital/clinic where your child’s health records are kept? Health History Questionnaire What are your child's most important health problems? List as many as you can in order of importance. Allergies Is your child hypersensitive or allergic to anything? Please list any prescription medications, over the counter medications, vitamins or other supplements your child is taking. Medical History Chicken Pox Scarlet Fever Bronchitis Mumps Frequent Colds Eczema Measles Pneumonia Croup Rubella Asthma Tonsillitis Ear Infection Other X-Rays and Special Studies When, Where, Results Electroencephalogram Psychological Hearing Speech/Language Family History Heart Disease Diabetes Hay Fever Mental Illness Hypertension Cancer Tuberculosis Allergies Arthritis Eczema Birth Defects Previous pregnancies by natural mother, miscarriages or complications: Mother's Age at Child's Birth Mother's Health During Pregnancy Bleeding Hypertension Cigarettes, Alcohol, Drugs Diabetes Nausea Thyroid Problems Physical or Emotional Trauma Illness Birth History Term Full Premature Late Weight at Birth Length of Labor Complications As a baby, did your child have any of the following problems? Jaundice Diarrhea Birth Defects Rashes Colic Fever Cerebral Palsy Allergies Blue Baby Seizures Birth Injuries Other Feeding Breast Fed? How Long? Formula/Milk Soy? Age When Your Child Began... Solid Foods Sitting Crawling Walking First Words Child's Sleep Patterns During First Year Injuries/Surgeries/Hospitalizations Immunizations Polio Tetanus Measles/Mumps/Rubella Pertussis Diphtheria Influenza Any Adverse Reactions? If yes, what? Symptoms Hives Eczema Flat Feet Nose Bleeds Acne High Fevers Chronic Rash Hearing Loss Diarrhea Sore Throats Gas Anemia Wheezing Cough Burning of Urine Bloody Urine Frequent Urination Motion/Car Sickness Vomiting Spells Sensitive to Light Stomach Aches Body/Breath Odor Sleep Problems Bleeding Gums Frequent Headaches Excessive Fatigue Bleeding Tendency Frequent Colds Dizzy Spells Cries Easily Nervous Easy Bruising Night Sweats Unusual Fears Jaundice Heart Murmur No Appetite Nightmares Canker Sores Constipation Joint Pains Hair Loss Any Other Condition Not Mentioned Diet Please Describe Your Child"s Typical Daily Diet Food Intolerances (If Known) **You will sign for this form when you come to the office** Thank you!
