Pediatric Intake Paperwork

Pediatric Intake Paperwork
Child's Full Name *

First Name Last Name
Date *

- Month - Day Year
Date
Date of Birth: *

- Month - Day Year
Date

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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 *
Social Security Number *
Your Occupation *
Your Employer *
Whom to contact in case of emergency? (please list relation and best contact number) *
Please provide your insurance information below:
Primary Insurance Company *
Group #: *
Member ID#: *
Relationship to Subscriber *

Claims Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Subscriber Name (if other than patient) *

First Name Last Name
DOB: *

- Month - Day Year
Date
Secondary Insurance Company *
Group #: *
Member ID#: *
Relationship to Subscriber *

Claims Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Subscriber Name (if other than patient) *

First Name Last Name
DOB: *

- Month - Day Year
Date

Personal Medical History
Who is your child's Physician? *
Please list complaints for your child in order of priority: *
Please list any allergies to medicine or foods and include the type of reaction (for example, anaphylaxis, stomach upset, rash, etc.): *

Please list pharmaceutical medicines you take, along with the dose: *

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

Please list any health supplements you take, 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 including dates: *
Date of your last physical exam: *

- Month - Day Year
Date
Any abnormal results? *
Date of your last blood work: *

- Month - Day Year
Date
Any abnormal results? *

Lifestyle

Daily Diet *

	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. Hayford to perform the following specific procedures as necessary to facilitate my diagnosis and treatment:

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

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

Medical use of Ozone Therapy: use of ozone/oxygen gas to treat skin conditions, infections, allergies and GI conditions. Ozone may also be used as an intra-muscular injection (Prolozone therapy) to decrease pain in a muscle or tendon and help to heal injuries.

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. Hayford 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 three, 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.
Signature *

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. Hayford will be billed at the same rate as an in-office visit *
I understand that I may message Dr. Marinaro’s/Dr. Hayford’s support staff through Patient Fusion. 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. *
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Pediatric Intake Paperwork

Personal Medical History

Family Medical History

Lifestyle

Terms of Consent for Care

New England Naturopathic Health Policies