Intake form template
Pediatric Intake, Ages 0–12 (Quick)
Short intake for a child patient — birth history, development, and current health.
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
- Written for a parent or guardian to fill in for a child from birth to age 12.
- It collects contact details for the parent or guardian, not the child, so it suits families with more than one guardian.
What it asks
18 questions across 9 short screens, shown one screen at a time so it works on a phone.
See every question
- 1. Child's first name · Child's last name · Child's date of birth
- 2. Parent/guardian name(s) · Parent/guardian phone · Parent/guardian email · Preferred contact method
- 3. Who does the child live with?
- 4. Was the child born full-term? · Any complications during birth?
- 5. Was the child breastfed? · Food allergies or intolerances
- 6. Does your child sleep through the night? · Typical bedtime
- 7. Health history — check any that apply
- 8. Developmental or physical concerns · Current medications or supplements
- 9. What's your goal for treatment?
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.