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Pediatric Intake Form

Infinity Health Inc.
Dr. Alexina Mehta
Naturopathic Physician
#215-2211 West 4th Ave
Vancouver, BC
V6K 4S2

The information in this form is kept in strict confidence and will be transmitted securely and directly to Dr. Mehta on 10/16/2021
Name:
Name:
First
Last
Gender:
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Address:
Address:
City
State/Province
Zip/Postal
Country

MEDICATION:

Aspirin Antibiotics

Now
Past

Tylenol Anti-histamine

Now
Past

Decongestant Other

Now
Past

Ibuprofen

Now
Past

MEDICAL HISTORY:

Checkboxes

Has your child had any of the following tests?
Please indicate: When, Where, Results:

IMMUNIZATIONS:

Please select all immunizations that apply:

FAMILY HISTORY:

Please select all that apply:

PRE-NATAL HISTORY

Did your child have any of the following after birth?
Please select all that apply:

BIRTH HISTORY:

Term:
Formula?

SYMPTOMS:

Hives
Burning of Urine
Bloody Urine
Eczema
Frequent Urination
Cries Easily
Bleeding Gums
Heart Murmur
Nervous
Nosebleeds
Vomiting Spells
Sleep Problems
Acne
Anemia
Night Sweats
High Fever
Stomach Aches
Sensitive to Light
Chronic Rash
Jaundice
Body/Breath Odour
Hearing Loss
Easy Bruising
Motion/Car Sickness
Diarrhea
Flat Feet
No Appetite
Sore Throat
Constipation
Nightmares
Headaches
Gas
Canker Sores
Frequent Colds
Bleeding Tendency
Unusual Fears
Wheezing
Joint Pains
Excessive Fatigue
Cough
Dizzy Spells
Hair Loss

DIET:

Please describe your child's typical daily diet:

Thank you for filling out this form. We look forward to working with your child.


CONSENT FORM

Dear Patients:
Naturopathic examination includes: physical and clinical diagnosis, traditional Chinese medical diagnosis, energetic testing and lab work. Therapeutic procedures may include: homeopathy, spinal adjustment, botanical medicine, acupuncture, manual muscle therapy, craniosacral therapy, bowen therapy, clinical nutritional, lifestyle counselling, biofeedback and mind-body awareness.

Occasionally, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing complications are minimal, it is the practice of this clinic to inform our patients about them. These complications may include, but are not limited to: soreness, inflammation, soft tissue injury, dizziness, burns, bruising, stroke, and temporary worsening of symptoms. More serious complications are extremely rare.

I have read and understand the above statements regarding potential treatment side effects. I also understand that there is no guarantee or warranty for a specific cure result.

I am aware that 24 hours notice must be given for all cancelled appointments or the full fee for the visit is due. I understand that I am responsible for payment at the time services are rendered. Dispensary items and lab tests must be paid for in full before leaving the office.

Please click this checkmark to indicate that you have read, understand, and agree to this consent form. Checking this box implies parental consent for applicants under the age of 19, for whom parental consent is required for naturopathic treatment.