Integrative Medicine | Holistic Healthcare

Integrative Medicine | Holistic Healthcare – Start Your Healing Here

INTEGRATIVE Family MEDICINE Center
Mind-Body Therapeutic Massage Nutrition Acupuncture

116-P Edwards Ferry Rd, NE
Leesburg, VA 20176
(703) 669-6118

Patient Forms

Confidential Patient Information Form

MS Word Adobe PDF


Records Release Form MS Word Adobe PDF


Privacy Notice MS Word Adobe PDF


These forms are available in two formats: Microsoft Word or Adobe PDF. To view and print a form, click on the corresponding link above and the page will open a new browser window. To return to this page, simply close the new window.

PEDIATRIC PATIENT FORM

Pediatric Intake Form

Name: ___________________________________________________________

DOB: ________________________

Parent’s Names:_________________________________________________________

Address: ________________________________________________________________

_______________________________________________________________________

Phone Numbers: _________________________________________________________

General Health Concerns: _________________________________________________

______________________________________________________________________

Pregnancy History: _______________________________________________________

_______________________________________________________________________

Birth History: ___________________________________________________________

_______________________________________________________________________

Neonatal History: _________________________________________________________

________________________________________________________________________

Blood type: _______________________________

Is/was your child breastfed? ________________________________

If so, for how long? __________________________________________________

___________________________________________________________________

Describe your child’s current diet: _______________________________________

___________________________________________________________________

Illnesses: ____________________________________________________________

____________________________________________________________________

Hospitalizations: ______________________________________________________

____________________________________________________________________

Surgeries: ____________________________________________________________

_____________________________________________________________________

Medications: __________________________________________________________

_____________________________________________________________________

Allergies to medications: _________________________________________________

______________________________________________________________________

Vitamins, Supplements: ___________________________________________________

_______________________________________________________________________

Immunization Status: __________________________________________________

_______________________________________________________________________

Is your child in daycare or school? ___________________________________________

Family History: __________________________________________________________

_______________________________________________________________________

Are there any particular concerns that you have about your child that you would like to discuss today? ___________________________________________________________

_______________________________________________________________________

Patient-Centered Medicine

Comprehensive Healthcare

Traditional and
Complementary Therapies

A Whole-Body Approach
to Health & Well-being