Pediatrics Intake Forms & Patient Questionnaires

A two-year-old presenting with recurrent ear infections and a fifteen-year-old coming in for a sports physical are both pediatric patients, but the information you need from their parents is fundamentally different. The toddler's intake needs birth history, NICU stay details, breastfeeding or formula history, and developmental milestones — is she walking, how many words, does she make eye contact. The teenager's intake needs immunization status for school requirements, menstrual history if applicable, mental health screening questions, and whether anyone has talked to them about vaping, substance use, or sexual health. An adult medicine intake form handles neither.

The Pediatrics intake form is structured around how pediatric offices actually work. It captures parent and guardian contact information (including custody arrangements and who is authorized to make medical decisions), birth history (gestational age, birth weight, delivery method, complications, Apgar scores), feeding history, and a developmental milestone checklist organized by age range. For school-age and adolescent patients, it includes sections on academic performance, behavioral concerns, screen time, physical activity, and an age-appropriate psychosocial screening.

What Makes Pediatric Intake Different

Pediatrics has intake complexities that no other specialty shares. The patient cannot fill out the form. The person filling it out might be a biological parent, stepparent, grandparent with legal custody, foster parent, or a nanny who was sent with the child and does not have half the medical history. The form needs to capture who is completing it, their relationship to the child, and whether they have legal authority to consent to treatment. In shared custody situations, you need both parents' contact information and a clear note about who holds medical decision-making authority.

Immunization records are another uniquely pediatric challenge. Parents show up with vaccine cards that are incomplete, lost, or from another state. The form includes a structured immunization history section — DTaP, IPV, MMR, varicella, Hep B, Hep A, rotavirus, PCV13, Hib, influenza, and HPV — with fields for dates and whether records need to be requested from a prior provider. School and daycare enrollment forms have strict immunization requirements, and your office is the one fielding calls when the records do not match.

Growth, Development, and Behavioral Screening

The intake captures growth percentiles and developmental screening results in a format your staff can update at each well visit. For infants and toddlers, it tracks gross motor, fine motor, language, and social-emotional milestones. For older children, it includes behavioral screening sections covering attention and focus, anxiety, mood changes, sleep patterns, appetite changes, and school performance. These are the questions that surface ADHD, anxiety disorders, and learning disabilities — conditions that parents often bring up obliquely ("he's having trouble in school") rather than directly.

Intake vs. Parent Questionnaire

The intake form is your internal office document. Your medical assistant or nurse fills it out during the visit from the chart and parent interview. The companion parent questionnaire is what you send home or email before the first appointment. It asks parents to list medications, allergies, prior surgeries, and specialist visits in plain language. It includes HIPAA authorization, consent for treatment of a minor, and a signature block. For new patients transferring from another pediatrician, the questionnaire includes a records release section so your staff can request prior charts without a separate form.

Pricing

Each form is $19.99 for the complete set (intake + questionnaire), $14.99 for intake only, or $9.99 for questionnaire only. All PDFs are fillable in Adobe Reader, password-protected against editing, and HIPAA-compliant.

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