Child Intake Form

Please take a moment to fill out our online intake form before your visit. All information is kept completely confidential.

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Date of birth

Day

Month

Year

Gender

Emergency Contact (Relationship)

Emergency Contact Phone

How did you hear about us?

What are your child's HEALTH CONCERNS/GOALS? List in order of priority.

List all CURRENT prescribed medications. (Name/Dosage/Length taken)

List all CURRENT vitamins, minerals, herbs that your child takes more than occasionally. (Name/Dose/Length taken)

List any prescribed medication your child had an ADVERSE REACTION to in the past. (Name/When taken/Reaction)

How many times have your child been treated with ANTIBIOTICS?

Has your child lived in a moldy home or been exposed to mold at school?

Please indicate if any of the above have caused an adverse reaction.

Has your child had any screening test (i.e. blood, hearing, vision)?

Yes

Other

How was your infant fed? (Breastfed and/or Formula fed, for how long?)

Did your child ever experienced colic?

Yes

Does your child have any food allergies or intolerances? Which foods?

Does your child have any dietary restrictions? (religious, vegan, vegetarian, etc)

What is your child's favourite food?

What is your child's least favourite food?

What was the health of the parents at conception? (Poor, Fair, Good, Excellent, Unknown)

Mother:

Father:

What was the mother's age at the time of this child's birth?

BIRTH HISTORY: Full/Premature/Late, Length of Labour, Child's Weight at Birth, Vaginal/C-Section/Induced/Forceps/Epidural

Describe your child's behaviour and performance at school.

Does your child exercise regularly? (Type/Frequency)

How much television does your child watch? (hrs/day or week)

What's her or his favourite TV program?

What's your child's favourite book?

Does anyone in the child's household smoke?

Yes

Are there any animals in the home? What kind?

How would you describe the emotional climate of the child's home?

I certify that the above medical information is correct to my knowledge.

PRIVACY AND SHARING OF INFORMATION: I authorize Dr. Ji Woon Min to collect my personal and medical information as documented above. In addition, I authorize Dr. Ji Woon Min to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

CANCELLATION POLICY: Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the schedule that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged the full consultation fee.

CONSENT TO MINOR: I AUTHORIZE Dr. Jiwoon Min, Naturopathic Doctor, who have been engaged by me to examine and provide Naturopathic care and treatment to my child.

NATUROPATHIC MEDICINE INFORMED CONSENT

Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. My ND will take a thorough case history and perform a relevant physical examination. It is very important that I inform my naturopathic doctor of any medical concerns or medication and supplements I may be taking. I will advise my ND if I am pregnant, suspect I am pregnant or if I am breastfeeding.

As a patient I will receive information about my diagnosis and/or treatment, alternative courses of action, the material effects, costs, expected benefits, risks, side effects and in each case the consequences of not having the diagnosis and/or treatment acted upon. As with any form of medical intervention there can be health risks associated with treatment by naturopathic medicine. Possible side effects of naturopathic medical care include:

Aggravation of pre-existing symptoms
Allergic reactions to supplements or herbs

I understand that my naturopathic doctor cannot prescribe over text, whatsapp or email without having a consultation to go over pertinent information such as my signs, symptoms and lab results to fully understand my situation to prescribe a customized treatment plan just for me.

I understand that the results are not guaranteed. I do not expect the naturopathic doctors to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to Naturopathic care I intend this consent form to cover the entire course of treatment. I understand that I am free to withdraw my consent at any time.

I UNDERSTAND AND GIVE CONSENT.

Child Intake Form

Dr. Ji Woon Min, Naturopathic Doctor