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Babies, toddlers, teenagers, and adolescents who are below the age of twenty-one are the age categories who are known as pediatric patients. This age category reminds healthcare providers and therapy counselors to seek parental consent or the approval of the patient’s legal guardian before any medical procedure will be provided to the patient. However, not only a signed consent form is necessary to be submitted by the parent of the pediatric patient, but also a pediatric intake form and the medical records of the patient.

Pediatric Intake Form Sample

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What is a Pediatric Intake Form?

A pediatric intake form is a document that pediatricians and pediatric therapist use for acquiring the information of a patient who belongs to the pediatric age category. This document must be accompanied by a consent to treat form, which will be signed by the patient’s legal guardian or parents, to permit the clinic in providing medical care to the patient. Other inclusions to be attached or enclosed with a pediatric intake form includes the mother’s medical history or pregnancy record to aid in determining if the child obtained his medical condition from his mother or upon birth.

Pediatric Medical History Intake Form

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Benefits of Using Pediatric Intake Forms

Pediatric intake forms allow pediatricians to connect and communicate with the patient as well as their concerned relatives and parents. Since the form collects the relevant medical details of the patient, the pediatrician or the therapist will be able to determine what method he must use to address and cure the patient’s condition. Using the form will also aid the therapist in constructing an effective interview questionnaire that will allow the parent in disclosing other information of the patient that corresponds the statements written on the form. However, the therapist or the patient’s pediatrician must not only rely on the form as it only serves as a preliminary or initial analysis for the patient.

Pediatric Patient Follow-up Intake Form

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Varieties of Pediatric Intake Forms

With the different types of medical procedures and methods that can be offered to pediatric patients, there must also be forms and documents to cater the medical details and concerns associated with every medical method. Below are the common varieties of pediatric intake forms that are used and provided to the parents of pediatric patients:

1. Naturopathic Pediatric Intake Form – If the parents of a pediatric patient aim to have their child undergo naturopathy or any type of therapy involving alternative medicine, then they must complete a naturopathic pediatric intake form. This document serves as a tool for the therapist to determine how he/she can address the concerns of the pediatric patient’s parents as well as know his/her patient better. It is significant that the parents will list the names of their child’s healthcare providers along with the contact information of each on the list in order to allow the therapist in reaching out to the child’s physician whenever necessary.

Naturopathic Pediatric Intake Form

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2. Pediatric Dentistry Patient Intake Form – The most common fear that children have aside from seeing clowns and spiders are having to visit a dentist. However, some children also know the good things that a dentist can give to them rather than the pain during tooth extraction. With this, the parents of children who want to arrange a scheduled session with the dentist for various oral concerns must fill out a pediatric dentistry patient intake form. This document is essential for introducing the child to the dentist as well as identifying the financial obligations of the parents regarding the dentistry procedures to be provided for the child.

The parents must affix their signatures on the form at the signature block located after the financial statement or arrangement provided by the dentistry clinic to indicate the parents’ approval or agreement. Additionally, if the child is a beneficiary of a dental insurance, then the parents must disclose their insurance information along with the location of the insurance company’s main office.

Pediatric Dentistry Patient Intake Form

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3. Pediatric Endocrinology Intake Form – If a pediatric patient has hormonal concerns as well as issues in his glands, then he must be sent to an endocrinologist who is an expert in addressing problems relating to growth, development, puberty, and diabetes. A pediatric endocrinology intake form will be given to the parents of the patient wherein they must supply the patient’s general information which should include his/her date of birth.

Compared to other forms, this document also has fewer sections and only focuses on questions that allow the parent to state their goals for visiting the clinic, the inquiries of the parent regarding their child’s issues, and significant data that the parents aim to inform the endocrinologist about their child for an easy identification of the problem. Once the form is submitted, the clinic staff will need to measure the child’s weight, height, and blood sugar in order to complete the fields of the form allotted for the initial assessment of the child.

Pediatric Endocrinology Intake Form

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4. Pediatric Health History Intake Form – Most pediatric intake forms will cater to the different information of a patient; however, a pediatric health history intake form will only be able to obtain all the relevant histories of a pediatric patient. The patient’s prenatal history, immunization and medical history, and his/her social and family history should be disclosed to complete the form. The significance of presenting the previous concerns and the state of the patient is due to the need of the therapist or his/her physician in conducting an assessment in determining where and how the patient’s condition started whether due to the genetic structure of the patient or from environmental causes.

Pediatric Health History Intake Form

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5. Pediatric Infectious Diseases Patient Intake Form – Measles, chickenpox, and influenza are the some of the known infectious diseases that children often obtain. For this, their parents must complete a pediatric infectious diseases patient intake form as they arrive at a clinic or at the healthcare provider’s office. The form is only a single-page document that centers on the important data of the child.

The first area of the form will indicate the date of the patient’s visit, the name and date of birth of the patient, the name of the caller or the person who inquired about the services of the healthcare provider, as well as the relationship of the caller with the patient, whether he/she is his/her parent or his/her legal guardian. If the patient was referred by a physician, then the name and the contact details of the physician must also be written on the form. You may also see family intake forms.

The second section of the form focuses on identifying the symptoms that the patient had and the medical examinations that the patient was able to take. The third section of the form deals with the insurance details of the patient ranging from the insurance identification number that his/her parents have up to the employment information of his/her parents. Lastly, the fourth section is allotted to be filled out by the staff of the clinic with the date and time of the patient’s appointment and the name of the staff who reviewed the entries on the form.

Pediatric Infectious Diseases Patient Intake Form

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6. Pediatric New Patient Intake Form – This document can be used by any pediatric healthcare provider since it obtains all the details of a pediatric patient. However, this form must only be provided to newly admitted patients and not to the returning patients of a clinic as part of the clinic’s health records.

Pediatric New Patient Intake Form

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Pediatric intake form varieties are not limited to the enlisted types since any healthcare provider can create other varieties depending on the data that they will be needing such as incorporating follow-up forms to their intake documents and questionnaires to assure that they will be able to conduct a medical verification of their patient’s concerns.

Pediatric Patient Intake Questionnaire Form

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Inclusions Found in a Pediatric Intake Form

Although pediatric intake forms are documents that will gather the information of a minor patient, this document must not be provided as a solo form, rather it must be accompanied by other medical forms and agreement documents. Four of the most common inclusions or enclosed documents in a pediatric intake form are patient financial obligations agreement forms, privacy notice forms, acknowledgment of receipt forms, and information disclosure consent forms.

The patient financial obligations agreement form is essential for informing the patient’s parents and legal guardian about their responsibilities in providing ample payment for the medical procedures as well as the medications of the patient. The privacy notice form, on the other hand, is significant for informing the parties about the rules and regulations of the clinic in disclosing crucial information to third-party entities.

An acknowledgment of receipt form is also important in the service verification procedure of the clinic, which must be signed by the patient’s parents to indicate that they aim to obtain and have received the services of the staff for their medical concerns and issues. Lastly, the information disclosure consent form will protect the patient’s information and data from being used without the consent of the patient or his/her legal guardians.

Simple Pediatric Intake Form

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With the aforementioned enclosed documents, a pediatric intake form will be effective in promoting a better relationship between the clinic staff, physician, and the parents of the patient. Nonetheless, the form must not only be kept into documentation by the clinic but must also be updated whenever the patient returns to the clinic for further analysis of his/her condition and acquire a cure. You may also see client intake forms.

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