Pediatric Intake Form

The Pediatric Intake Form is tailored specifically for children's healthcare needs. Unlike a standard adult intake form, this template captures child-specific information including birth history (delivery type, birth weight, APGAR scores), developmental milestones, immunization records, school and grade level, and behavioral or learning concerns.

Parent and guardian information is collected separately with clear relationship designation, ensuring that communication and consent workflows are properly managed. The form supports multiple guardians and includes fields for custody-related notes when relevant.

This template is ideal for pediatricians, family medicine practices seeing children, pediatric specialists, and school-based health clinics. The immunization records section can be pre-populated with the CDC recommended schedule, making it easy for parents to indicate which vaccines their child has received. Developmental milestone checklists are age-appropriate and aligned with AAP guidelines.