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902-894-3868
[email protected]ndsmcmurrer.com

Simmonds McMurrer

Naturopathic Clinic

About
Services
Team
Au Natural TV
Get Started
- Adult Intake Form
- Child Intake Form
BOOK APPOINTMENT

Child Intake Form

Step 1 of 7

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- Child's Name*
  First Last
- Date of Birth*
  MM slash DD slash YYYY
- Health Card #*
- Insurance Provider*
- Naturopathic Coverage/Year*
- Parent's Name*
  First Last
- Parent's Name*
  First Last
- Email*
- Phone (home)*
- Phone (work)*
- Phone (cell)*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- How did you hear about us?*
- Your Child’s Pediatrician and/or Medical Doctor*
- Specialists*
What is your primary concern regarding your child’s health?*
What else would you like to see changed in his/her health?*

What medication(s) is your child currently on?
- Medication
- Reason
- How long
- Medication
- Reason
- How long
- Medication
- Reason
- How long
- Medication
- Reason
- How long
What supplements or vitamins does your child take on a regular basis?
- Supplement (including dose)*
- Supplement (including dose)*
- Supplement (including dose)*
- Supplement (including dose)*

What was the level of health of both parents prior to conception?
- Father*
  - Fair
  - Good
  - Excellent
- Mother*
  - Fair
  - Good
  - Excellent
What was the level of health of the mother during pregnancy?*
- Poor
- Fair
- Good
- Excellent
Comments*
What supplements did you take during pregnancy?
- Supplement*
- Dose*
- Supplement*
- Dose*
Did you use any of the following during pregnancy?
- Cigarettes*
- # times/day
- Alcohol*
- # times/day
- Vaping*
- # times/day
- Cannabis*
- # times/day
- Other Drugs*
- # times/day
What medications were you on during pregnancy?
- Prescribed*
- Over the counter*
- Prescribed*
- Over the counter*
- Prescribed*
- Over the counter*
- Prescribed*
- Over the counter*
How was your diet during pregnancy?*
- Poor
- Fair
- Good
- Excellent
Birth of the child, please check all that apply:*
- Induction
- Epidural
- Vaginal Birth
- C-Section Birth
Were there any complications?*

Please give a detailed history of the present health concern and symptoms.*
What are your observations about your child’s temperament?*
- Was your child’s physical development*
  - Slower than average
  - Average
  - Faster than average
- Was your child’s emotional/mental development*
  - Slower than average
  - Average
  - Faster than average
How was your child’s behaviour and performance in school?*
Are the child's parents*
- Married
- Common Law
- Separated
- Divorced
- Remarried
Do any members of the household smoke?*
- Yes
- No
Do either the child’s mother or father have a chronic illness? What is their general state of health?
- Mother*
- Father*
- Are there brothers or sisters? Please list name, age, and state of health.*
- What is the emotional state of the child’s home presently?*

Family History
Are there any of the following diseases in grandparents, parents, or siblings:
- - Diabetes Type I
  - Diabetes Type II
  - Cancer
  - Heart Disease
- - Mental Illness
  - Alzheimer’s Disease
  - High Blood Pressure
- - Thyroid Disease
  - Kidney Disease
  - Chronic Pain/Inflammation
- - Tuberculosis
  - Arthritis
  - Digestive Disorders
Please specify any Digestive Disorders
Please specify which type of Arthritis

NATUROPATHIC DECLARATION AND CONSENT TO TREATMENT
This is to acknowledge that I have been informed and understand:
1. Any treatment or advice provided to me as a patient of the clinic is not mutually exclusive from any treatment or advice that I may now be receiving or may receive in the future from another licensed health care provider.
2. I understand that Naturopathic Medicine is a comprehensive approach to health and illness and focuses on prevention and the use of natural, non-invasive methods of treatment and assessment.
3. I understand that any recommended treatments will be explained to me by the naturopathic doctor and that I will give consent to treatment based on informed consent.
4. I am at liberty to seek and/or continue medical care from a medical doctor or other qualified health care provider.
5. I am aware that no part of my treatment or testing is covered by Health PEI and that I am solely responsible for payment.
6. Payment is to be made in full at the time of my treatment. We will provide you with a receipt for submission to your insurance company when services are rendered.
7. Cancellation Policy: If you cannot make a scheduled appointment, please call 24 hours in advance to reschedule. Patients will be charged the full fee for a missed appointment.
Consent*
I have read, understood, and agree to the above statements.
Signature, Patient or Legal Guardian*
Date of Consent*
MM slash DD slash YYYY
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Simmonds McMurrer Naturopathic Clinic

Whether you are currently suffering from a chronic or acute medical condition or wish to prevent future illness, naturopathic medicine has something to offer you.

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34 Queen Street, 2nd floor
Charlottetown, PE C1A 4A3
902-894-3868
Fax: 902-894-4054

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