Female Intake Form

Please complete this form and submit to info@shinehealthasheville.com.

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Shine Health PLLC
201 Stone Ridge Blvd.
Asheville, NC 28804
(828)785-1850

Pediatric Intake Form

Date: __________________________
Patient Last Name: __________________________ First: ____________________________
DOB: _____________________ Age: _________ Sex: M / F
SSN: __________________________
Street Address: ______________________________________________________________
City: ________________________________ State: _____ Zip Code: _____________

Parent/Guardian Contact Information:
Name: _______________________________________ Relationship: __________________
Home Phone: ________________________ Cell Phone: _____________________________
Work Phone: ________________________
Please circle preferred contact number.
Is it OK to leave a voice mail? Y / N
Parent/Guardian email address: ________________________________________________
Insured: Y / N
Insurance Provider: _____________________________________

Emergency Contact Information (in the event parent/guardian is not reachable)
Name: ______________________________________ Relationship: ___________________
Contact Number: _____________________________

How did you hear about us? ___________________________________________________

When did your child last receive health care and for what reason?

Reason for today’s visit:

Has your child been seen by any other providers for this health concern? Y / N

Please list your child’s health concerns or goals in order of importance:
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
4. ________________________________________________________________
5.________________________________________________________________

Please include any medication your child is currently taking.
Please include any over the counter medications.

Medication Indication Date Started Dose/Frequency Helpful Y/N

Please list all supplements your child is currently taking including vitamins, minerals, herbal, homeopathic, etc.

Supplement Indication Date Started Dose/Frequency Helpful Y/N

Please list any known drug, food or environmental allergies.

Drug/Food/Allergen Response to Drug/Food/Allergen

Mother’s Prenatal/Perinatal Health History:

Age of Conception: ____________
First Pregnancy? Y / N If not, pregnancy #: __________
Smoking: Y / N
Coffee/Caffeine Use: Y / N
Recreational Drug Use: Y / N
Emotional Stress: Y / N
Nausea/Vomiting: Y / N
Diabetes: Y / N
Vaginal Birth: Y / N
Length of Labor: _____________
Traumatic Birth: Y / N
If yes, please describe: ______________________________________________
_________________________________________________________________
Breast fed: Y / N. If yes, for how long? _____________________
Formula: Y / N If yes, type: ____________________________

Did your child satisfactorily meet all developmental milestones (to this point)? Y / N
If no, please describe: _________________________________________________
____________________________________________________________________

Past Medical History:
Has your child received childhood immunizations? Y / N
Were they administered on the standard schedule or a delayed schedule? S or D
Did you child receive any COVID-19 vaccines and boosters? Y / N

Immunization Record:

Immunization Date(s) Received Any Adverse Effects?

Any Hospitalizations? Y / N
If Yes, please describe:

Date Reason for Hospitalization Length of Stay

Any Surgical Procedures? Y / N

Date Surgery Any Complications?

History of Antibiotic use? Y/N
If yes, please describe:

Past History:
Please check any applicable boxes below:

Condition Past Current
Jaundice
Colic
Cradle Cap
Anemia
Asthma
Eczema
Behavioral Issues

Bedwetting
Early Puberty
Excessive Sweating
Picky Eater
Frequent Earaches
Irritable
Frequent Sore Throats
Frequent Colds

Condition Yes No Never Tested
Normal Hearing
Normal Vision
Speech Impediment
Learning Disability

Please expand on any of above:

Family History:
Please indicate whether the child or family members has or had any of the following conditions:

Member Auto
immune Cancer Cardio
Vascular Diabetes Mood
Disorders Neuro
Disease Thyroid
Child
Mother
Father
Sibling
Sibling
Sibling
Sibling

Member Auto
immune Cancer Cardio
Vascular Diabetes Mood
Disorders Neuro
Disease Thyroid
Maternal
Grandmother
Maternal
Grandfather
Paternal
Grandmother
Paternal
Grandfather

Any additional comments regarding family history:

Review of Symptoms:

Please circle any symptoms your child is having currently or in the last 2 weeks.
Please feel free to write in any additional symptoms or comments.

General: Weakness, Chills, Fatigue, Night Sweats, weight gain or loss of 5+lbs in the last 30 days
Head: Trauma, Dizziness, Headaches, Lightheadedness, Migraines, Hair Loss, Dandruff
Ears: earache, ringing in ears, discharge from ears, vertigo (dizziness), hearing loss, trauma to the ear
Nose: Sinusitis, congestion, loss of smell, nosebleeds, discharge, nasal fracture, polyps
Mouth & Throat: oral lesions, difficulty swallowing, bleeding or sore gums, sore throat, cavities, teeth grinding, hoarseness, impaired speech.
Neck: trauma, swollen glands, pain or stiffness
Respiratory: asthma, bronchitis, chronic cough, pneumonia, wheezing, TB, difficulty breathing
Cardiovascular: heart murmur, chest pain, palpitations, rheumatic fever, known heart disease or cardiac anomaly, swollen feet/ankles, cool feet, change of color of hands or feet
Gastrointestinal: change in appetite, Heartburn, belching, change in stool, gas/bloating, liver disease, jaundice, abdominal pain, nausea, vomiting, diarrhea, constipation, change in stools, rectal pain or itching, undigested food in stool
Genitourinary: urgency, frequency to urinate, painful urination, frequent urinary tract infections, incontinence, bedwetting
Musculoskeletal: Joint pain or stiffness, history of fractures (broken bones), joint swelling, muscle cramps or spasms, tenderness over muscles, muscle aches
Neurological: numbness/tingling, seizures, fainting episodes, dizziness, tremors, balance issues, cognitive issues (memory, recall, concentration/focus), meeting developmental milestones
Endocrine: heat/cold intolerance, excessive thirst, excessive hunger, excessive urination, easy bleeding/bruising, anemia, low energy/fatigue
Skin: Acne, boils, itching, rashes, hives, bruising, change in skin color, moles, eczema, dryness.
Mental/Emotional: anxiety/nervousness, excessive fear, depression, mood swings, easy to anger, restlessness, suicidal thoughts, tension/stress.

Health Habits:
Teens: Alcohol Use?
Smoking?
Recreational Drug Use?

Chemical/Environmental Exposures?
Water Bottles?
Mercury Fillings?
Live near a farm, chemical or industrial plant?
Live in a city?
Car exhaust?
Household Chemicals/Cleaners?
Fabric Softeners?
Fragrances in home products/personal products?
Flouride toothpaste?
Conventional deodorants?
Wood Burning stove
Gas Heat
Mold/Mildew Exposure (home/car/school)
Pesticides/Herbicides
Clean water source?
Other:

Have you noticed any changes in your child’s sleeping habits? Y / N
How many hours does your child sleep?
Do they sleep through the night?
Do they nap during the day?
Insomnia?
Difficulty falling asleep?
Difficulty staying asleep?

Does your child currently exercise?

Describe your child’s energy level on a scale of 1-10 (1=low, 10=high):
Best time of day:
Worst time of day:

Does your child watch TV?
How many hours a day?
Does your child play video games?
How many hours a day?
Does your child use an ipad/cell phone/ have computer access?
How many hours a day?

Does your child have difficulty with school?
Academic performance?
Behavioral issues?
Bullying?
Social Issues?

Is your child stressed at home?
At school?
At social events?
Please comment/expand on any stressors:

Does your child have good coping mechanisms to handle stress? Please list:

Please list your child’s hobbies and interests:

Please list any concerns that have not been addressed on this form:

Female Intake Questionnaire.pdf