Intake form template
Pediatric Health History, Ages 0–12 (Comprehensive)
Health history for a child patient: family, pregnancy and birth, development, feeding, sleep, digestion and past conditions.
A starting point, not legal or medical advice. Read the full note
This is the form your patients would see. It’s a preview: nothing you enter is saved.
About this template
- A full health history for a child from birth to age 12: pregnancy and birth, development, feeding, sleep, digestion and past conditions.
- It's long. Consider sending it ahead of the first visit.
What it asks
69 questions across 24 short screens, shown one screen at a time so it works on a phone.
See every question
- 1. Parent or guardian name(s) · Child's name · Child's age · Email address
- 2. Street address · City · State · Postal code
- 3. Home phone · Work phone
- 4. Who does the child live with? · How many siblings and step-siblings? · Is the child in childcare or school?
- 5. Father's age at the child's birth · Mother's age at the child's birth · Was the child adopted? · Did the mother receive prenatal care?
- 6. Did the mother use any of these during pregnancy? · Please list what the mother used
- 7. Did the mother experience any of these during pregnancy?
- 8. Was the birth premature or overdue? · If overdue, by how many days? · Length of labor · Weight at birth
- 9. Who delivered the baby, and where? · How was the child born? · Was anesthesia used?
- 10. Anything else about the birth? · Any birth complications?
- 11. At what ages did your child first sit up, crawl, walk, talk, attend day care, use a cup and feed themselves?
- 12. Growth percentile at the last check-up · Date of last check-up
- 13. Was your child breastfed? · For how long was your child breastfed? · Was your child bottle-fed? · For how long was your child bottle-fed?
- 14. Which formulas were used? · Does your child still get a bottle? · At what age were solid foods introduced?
- 15. What foods were introduced before 6 months? · What foods were introduced between 6 and 12 months?
- 16. Food allergies or intolerances · How would you describe mealtimes?
- 17. Does your child sleep through the night? · How many times does your child wake per night? · Does your child wake for diaper changes? · If so, for what? · How many diaper changes per night?
- 18. Does your child wake for nighttime feedings? · Does your child wake with any of these? · Does your child fall asleep easily?
- 19. Bedtime · Wake-up time · How many hours does your child sleep at night? · How many naps per day? · How long are the naps?
- 20. Any recent change in bowel movements or stool consistency? · How long ago did it change? · How many bowel movements per day? · Is it hard to pass stool? · Does your child cry when passing stool?
- 21. What is the stool consistency? · What is the stool smell and content like?
- 22. Which of these has your child had, now or in the past?
- 23. Anything to explain about their health history? · Developmental or physical concerns, in order of importance to you · Any Western medical diagnoses?
- 24. Does your child have a special attachment to an item? · What is it?
How to use it
- Add it to Goji. You get your own editable copy.
- Reword or remove anything that doesn’t fit your practice, and have the wording reviewed where it matters.
- Send patients the public link, or embed the form on your own website.
- Answers arrive in your submissions inbox, ready to become a patient record.
Questions about this intake form template.
Do patients need an account to fill this out?
No. Once you add it to Goji, the form gets a plain public link that opens on any phone or computer with no account, password, or app. You can also embed it on your own website.
Can I change the questions?
Yes. Adding a template creates your own copy in the form builder, where you can reword, reorder, add, or remove any question before you share it. Changing your copy never changes the template.
Is this template legal or medical advice?
No. It is a general starting point. Check what your state or country and your profession require, ideally with an attorney or your licensing board or association, before you use it with patients.
A template, not advice
These templates are general starting points, not legal, medical, or compliance advice. Review and adapt every template for your practice, and check the requirements in your state or country and for your profession with a qualified professional, such as an attorney or your licensing board or association, before you use it. Goji doesn't guarantee that a template meets any law or standard.