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Mast Clinic Patient Intake Form
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Patient Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Parents’/Guardians' Names
Your answer
Address
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City
Your answer
State
Your answer
Zip
Your answer
Phone
Your answer
Email*
Your answer
*reports and some correspondence will be emailed for your convenience
Child's Physician
Your answer
Parents’/ Guardian's Employers
Your answer
Chief Complaint (please state the reason for bringing your child to Mast Clinic):
Your answer
When did the problem begin?
Your answer
Do you think there is anything that brought this problem on?
Your answer
What makes the problem worse?
Your answer
What makes the problem better?
Your answer
Does anyone in your family have the same problem? If so, who?
Your answer
Describe your concerns for your child
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Were there problems during pregnancy?
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Premature? If so, how early?
Your answer
Birth Weight
Your answer
Length of hospital stay
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Complications at birth or neonatal period
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Problems during infancy?
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What is your child’s diagnosis?
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When was the diagnosis first made?
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By whom?
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Current other problems
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Does your child take medications? Please list:
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At what age did your child reach the following milestones? Rolling, Sitting, Crawling/Scooting, Walking.
Your answer
What are your child’s strengths?
Your answer
Who does your child like to play with?
Your answer
What are your child’s favorite toys?
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What behavior patterns does your child have that you are concerned about?
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Does your child live at home?
Yes
No
Other:
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Who lives with the child? (Please include names and ages of all people)
Your answer
What things are hard for your child to do?
Your answer
What do you hope your child will learn to do?
Your answer
Are there other concerns you have about your child?
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What do you think Mast Clinic's services can do for your child?
Your answer
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