Child Intake Form (Newborn to 15 years old) 1 2 3 4 5 Thank you for your interest in becoming a client at Essex Nurse Practitioner Led Clinic. The ECNPLC collects, uses and discloses personal information in compliance with the guidelines of the Personal Health Information Policy Act (PHIPA). The priority of the ECNPLC is to provide primary health care services to residents who live in Essex and surrounding communities who do not have a primary care provider. Please answer the following questions to the best of your knowledge. Preferred Location Please select the ECNPLC location you are registering for: —Please choose an option—EssexWindsor (Drouillard)Amherstburg Personal Data Name: Date of Birth: Gender: —Please choose an option—MaleFemale Health Card Number: Version Code: Exp Date: Mailing Address: Parents/Guardians: Parent #1: Phone: Parent #2: Phone: Who lives in the household? (check off all that apply) MotherFatherSisterBrotherOther If other, who? Total number of people in the home: Email of parent: Do you consent to receiving email communication? This form of communication will not include any personal health information and is strictly one-way. You will not be able to email us. YesNo Name and location of the pharmacy you use: Child's previous doctor or nurse practitioner: List any previous specialists the child has seen in the past: Previous Next Birth History This child is: —Please choose an option—Biological (by birth)AdoptedStep-childFoster Was the pregnancy full term? —Please choose an option—YesNoDon't know Were there any complications with the pregnancy or delivery? —Please choose an option—YesNoDon't know If yes, please explain: Child's weight at birth: Growth and Development Have you or any previous care providers had any concerns with your child's development (speech, language, social skills, or motor skills)? If yes, please include as much detail as possible. Previous Next Medical History Has your child had any of the following conditions? Serious medical illness YesNo Details: Asthma/wheezing/breathing problems YesNo Details: Hospitalization and/or surgery YesNo Details: Broken bones/injuries YesNo Details: Behavioral problems YesNo Details: Depression or anxiety YesNo Details: Other? YesNo Details: Please list allergies to medications, food, or environment (penicillin, dust, pollen, dogs, etc.) Please list current medications, vitamins, and supplements (even if not used every day) or attach a copy of an up-to-date medication list from your pharmacy. Do you have an extended drug plan? (eg Greenshield, Desjardins, Sunlife) YesNo Previous Next Family History Please indicate if any blood relatives have suffered any of the following conditions. If yes, please indicate which family members (e.g. Parent, sibling, grandparent, and, uncle, etc.) had the condition. Alcoholism/Drug use? YesNo Who? High cholesterol? YesNo Who? High blood pressure? YesNo Who? Stroke? YesNo Who? Mental health problems YesNo Who and what type? Diabetes YesNo Who and type? Cancer YesNo Who and what type? Bleeding/clotting disorder YesNo Who? Genetic disorder YesNo Who and what? Asthma/COPD YesNo Who and which one? Diet and Exercise Is your child physically active? YesNo How do you rate your child's diet? GoodFairPoor Is your child a picky eater? YesNo Does the child use any of the following? (check all that apply) NoneAlcoholDrugsTobacco Is the child exposed to second hand smoke in the home? YesNo Previous Next Immunizations Please provide a detailed list of the child's immunizations/vaccinations and the date received: Please list any other information or health concerns that you feel we should know. I understand that the information I have provided is accurate to the best of my ability. I understand that this information will remain private and confidential, only to be used by the medical personnel at ECNPLC. Previous Next
