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Pediatric Intake Form

3 pages•20 fields•HIPAA-ready
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Child's Name & Date of Birth
Parent/Guardian Information
Birth History (Weight, Delivery Type)
Developmental Milestones
Immunization Records
Diabetes
Hypertension
Asthma
Heart Disease
Allergies
Current Medications
School & Grade Level
Behavioral Concerns
Insurance Information
Insurance carrier & policy
Consent Signature (Parent/Guardian)
I agree to the terms above
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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.

What's included

  • Child demographics and parent/guardian info
  • Birth history and developmental milestones
  • Immunization records aligned with CDC schedule
  • Allergy documentation with severity levels
  • Medication list with dosage and frequency tracking
  • Insurance information collection with carrier and policy details
  • Parent/guardian consent agreement with e-signature
  • Medical conditions checklist

Who uses this template

  • Pediatric practices and children's clinics
  • Family medicine offices seeing children
  • School-based health clinics
  • Pediatric specialty referrals

All form fields

11 fields across 3 pages. Customize any field after signing up.

Child's Name & Date of BirthText
Parent/Guardian InformationText
Birth History (Weight, Delivery Type)Text
Developmental MilestonesCheckbox
Immunization RecordsConditions
AllergiesAllergies
Current MedicationsMedications
School & Grade LevelText
Behavioral ConcernsLong Text
Insurance InformationInsurance Info
Consent Signature (Parent/Guardian)Consent Agreement

Use this template

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$79.99/mo · 14-day free trial · HIPAA compliant

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