Pediatric Intake Paperwork

Pediatric Intake Paperwork
Child's Legal Name *

First Name Last Name
Child's Birth Sex *
Child's Preferred Pronoun *
Today's Date *

Month Day Year
Date
Legal Guardian's Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone *

Area Code Phone Number
Work Phone *

Area Code Phone Number
Home Phone *

Area Code Phone Number
Email *
example@example.com
Preferred Method of Contact *
Child's Date of Birth: *

Month Day Year
Date
Child's Social Security Number *
Your Occupation *
Your Employer *
Whom to contact in case of emergency? (please list relation and best contact number) *
Personal Medical History
Please list complaints for your child in order of priority: *
Please list any allergies and reactions to medicines or foods your child has: *

Please list pharmaceutical medicines your child takes, along with the dose: *

	Medication name	Dose	Frequency (how often you take medication)
1
2
3
4

Please list any health supplements your child takes, along with the dose: *

	Health Supplement name	Dose	Frequency (how often you take medication)
1
2
3
4

Please list any major illnesses, accidents or hospitalizations your child has experienced including dates: *
Preferred pharmacy (name and address): *
Child's pediatrician (name and address): *
Date of your child's last physical exam: *

Month Day Year
Date
Any abnormal results? *
Date of your child's last blood work: *

Month Day Year
Date
Any abnormal results? *

Family Medical History
Do any members of your immediate family suffer from any of the following health conditions? If so, please explain in the text areas provided. Please specify which family member:
Heart Disease/High Blood Pressure/High Cholesterol: *
Diabetes: *
Cancer: Type? *
Alcoholism/Drug Addiction: *
Mental Health Disorder: Type? *
Asthma/Respiratory Issues: *
COPD: *
Stroke: *
Liver Disease: *
Kidney Disease: *
Digestive Issue or Diagnosis: *
Arthritis *
Vision Problems: *
Any other serious health conditions? *
Does your child have any problems with any of the following body systems?
EENT (head, ears, eyes, nose, throat)
Endocrine (thyroid or another hormone imbalance)
Nervous system (dizziness, imbalance, slow thinking, poor memory)
Respiratory (allergies, asthma, chronic cough)
Skin (psoriasis, eczema, acne)
Cardiovascular (heart palpitations, chest pains, colds hands and feet, varicose veins)
Digestive (GERD, heartburn, nausea, constipation, diarrhea, gas, bloating)
Musculoskeletal (chronic back or limb pain)
Psychological (anxiety, depression)

Lifestyle

Please provide examples of typical meals: *

	Please Provide examples of typical meals
Breakfast
Lunch
Dinner
Snacks

How much water does your child drink in a day? *
Does your child exercise? If so, please list types and amount per week: *
Are there any problems with sleep? How many hours does your child typically sleep in a night? *
Please list your health goals for your child in order of priority: *

Terms of Consent for Care
I... *

First Name Last Name
hereby authorize Dr. Marinaro/Dr. Froman to perform the following specific
procedures as necessary to facilitate my child’s diagnosis and treatment:

Common diagnostic procedures: e.g., venipuncture, radiology, laboratory, X-ray, paps

Minor office procedures: e.g., cleaning, dressing a wound, ear lavage, skin scraping

Medical use of nutrition: therapeutic nutrition, nutritional supplementation, and intramuscular vitamin injections.

Botanical medicine: plant substances may be prescribed as teas, alcohol-based tinctures, glycerites, capsules, tablets, creams or suppositories

Homeopathic medicine: the use of highly dilute quantities of naturally occurring plants, animals and minerals

Craniosacral Therapy, Visceral Manipulation: gentle forms of bodywork used to address back pain and other musculoskeletal complaints, headaches and organ dysfunction

Counseling: utilization of mental health counseling and techniques

Medical use of Ozone Therapy: therapeutic ozone gas administered to isolated parts of the body, combined with depuration in an ozone sauna and injected subcutaneously or intramuscularly to address chronic pain and infections

I recognize the potential risk and benefits of these procedures as described below:

Potential risks: allergic reactions to prescribed herbs and supplements, side effects of medications or vaccinations, aggravation of pre-existing symptoms, discomfort, pain, infection, burns, nausea, light headedness, inconvenience of lifestyle changes, injury from injections, venipuncture or procedures. Please notify Dr. Marinaro/ Dr. Froman if you experience any symptoms which may be secondary to the above procedures.

Potential benefits: restoration of health and the body’s maximal functional capacity without the use of drugs or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or it’s progression.

Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by physician, or any personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or my representative or unless it is required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee. I understand that my medical record will be kept for a minimum of seven years, but no more than ten years after the last day of my visit. I understand that information from my medical record may be analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that any questions I have will be answered by my practitioner to the best of his/her ability.

I understand that all sales of goods and services are final. Refunds for supplements up to 90 days after purchase (unopened items only).
Signature of Legal Guardian

Clear
Date *

Month Day Year
Date

New England Naturopathic Health Policies

Please initial in the following boxes:
I understand that payment of consultation fees, lab fees, supplements and any other services are due at the time of service. *
I understand that phone consultations and phone lab reviews with Dr. Marinaro/Dr. Froman will be billed at the same rate as an in-office visit *
I understand that I may message Dr. Marinaro’s/Dr. Froman’s support staff through Charm. Email is not an acceptable communication format due to confidentiality concerns. *
I understand that any supplements purchased at NENH or via Health Wave (per NENH request) cannot be returned once opened. *
I understand that if I am more than ten minutes late for an appointment. I may not be seen and may be assessed a cancellation fee. *
I understand that should I miss an appointment or cancel with less than a twenty-four hours’ notice, I will be assessed a cancellation fee. *
I understand it is my responsibility to ensure insurance coverage for both office visits and labs ordered by a Naturopathic Doctor. Please refer to the Insurance Benefits Verification form for additional information. *
I understand that Naturopathic doctors in the state of Maine serve as specialists and not primary care doctors. For this reason, I understand that it is my responsibility to have a PCP, or to be actively looking to establish care with a PCP, prior to establishing care at New England Naturopathic Health. *
Patients must be seen at a minimum of once annually to maintain their place in the practice; patients who have active prescriptions through NENH must be seen every 6 months to maintain the prescription.
Should be Empty:

Pediatric Intake Paperwork

Personal Medical History

Family Medical History

Lifestyle

Terms of Consent for Care

New England Naturopathic Health Policies