Pediatric Patient Intake Form: What to Collect for Children's Health Visits

Pediatric intake is a three-way process: the patient, the parent or guardian, and the provider. The person filling out the form isn't the person being treated, which changes everything about how you structure questions, who signs consent, and what information you prioritize.

A well-designed pediatric intake form accounts for this dynamic and captures the developmental, family, and social context that makes children's healthcare fundamentally different from adult care.

Parent/Guardian Information

This comes first, not the child's demographics. You need:

• Parent/guardian full name
• Relationship to child (parent, grandparent, legal guardian, foster parent)
• Contact information (phone, email, address)
• Legal custody status: who has authority to consent to treatment
• Secondary parent/guardian information, if applicable
• Emergency contacts (at least two, with relationship noted)

If someone other than the parent/guardian brings the child in, you need a consent-to-treat authorization on file. Build this into the form with a conditional question: "Will someone other than the parent/guardian bring the child to appointments?"

Child Demographics

Name, date of birth, age, sex, preferred name or nickname. For pediatric practices, age is calculated differently. An 8-month-old and an 8-year-old have completely different clinical needs, so date of birth is essential for age-appropriate screening and vaccine scheduling.

Birth and Neonatal History

Critical for infants and young children, still relevant through school age:

• Gestational age at birth (full term, premature, weeks)
• Birth weight and length
• Type of delivery (vaginal, C-section)
• Complications during pregnancy or delivery
• NICU stay (duration and reason)
• Newborn screening results

Use conditional logic here. If the child is over 5, you might simplify this section. For an infant's first visit, you want every detail.

Immunization History

One of the most important sections:

• Immunization records (file upload for existing records)
• Is the child up to date on vaccinations?
• Any vaccines declined or delayed, and reason
• Reactions to previous vaccines

A file upload field for existing immunization records saves enormous time compared to asking parents to remember dates and vaccine names from memory.

Developmental Milestones

Tailor these by age group:

• Infants: rolling, sitting, crawling, first words, feeding method
• Toddlers: walking, word count, toilet training, social interaction
• School-age: academic performance, reading level, attention and focus, friendships
• Adolescents: puberty status, mood and behavior changes, social concerns

A single developmental section doesn't work across all ages. Use conditional logic tied to the child's date of birth to show age-appropriate milestone questions.

Medical History

• Known diagnoses and chronic conditions
• Previous hospitalizations or surgeries
• Current medications (name, dose, frequency)
• Allergies (medications, food, environmental)
• Family medical history, particularly conditions with genetic components (asthma, diabetes, heart disease, mental health conditions, developmental disorders)

School and Social Information

• School name and grade
• Learning accommodations (IEP, 504 plan)
• Childcare arrangement
• Household composition (who lives in the home)
• Pets in the home (relevant for allergies and zoonotic exposure)
• Dietary information and any restrictions

Insurance

• Primary insurance carrier and member/group ID
• Subscriber information (usually a parent)
• Secondary insurance, if applicable
• Medicaid or CHIP, if applicable

Consent

Parental consent for treatment is legally required for minors. Your form needs:

• Consent for examination and treatment
• Consent for immunizations
• HIPAA privacy acknowledgment
• Photo/imaging consent
• E-signature of parent or legal guardian (not the child)

Building a Pediatric Intake Form

Formisoft handles the complexity of pediatric intake well. Use the AI builder to generate a base form, then add conditional logic tied to the child's age so the developmental questions and birth history sections adapt automatically. Multi-page layout keeps parents from getting overwhelmed, and the e-signature field handles parental consent cleanly.

Send the form via magic-link email before the appointment. Parents fill it out at home where they have access to immunization records, insurance cards, and medication bottles, not at the front desk while holding a toddler.

Get started with Formisoft and build your pediatric intake form today.