Pediatric Intake Form
Child intake completed by a parent: birth and development history, immunisations, current concerns, school and family context, and consent to treat.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 28 questions, 3 pages, 4 conditional rules.
- Questions
- 28
- Pages
- 3
- Layouts
- classic · card
- Time to complete
- ≈ 9 min
- Conditional rules
- 4
Searches this template answers
- paediatric intake form
- child patient intake form template
- pediatric new patient form online
- child health history form
- parent completed intake form
- children's clinic registration form
Also filed under
Live preview and test console
This is the real form. Answer it to test the flow — nothing is sent or stored.
Page 1 of 3 — Child and family
This template runs as a straight sequence — no branching rules.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
Who this template is for
Pediatric Intake Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 28 questions across 3 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 17 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It collects a verified email address so replies and confirmations land.
- It captures a phone number for urgent follow-up.
- It records a signature you can keep as proof of agreement.
- It pins the request to a specific date.
- It captures a full postal address.
- It allows multiple selections without free text.
- It captures a numeric value you can filter and sort on.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Pediatric Intake Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 4 conditional rules ship with it.
- Features conditional validation: if “Has any professional raised a concern about development?” is Yes, “Who raised it, and what was said?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Are immunisations up to date?” is No, “Which ones are outstanding, and why?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Is support already in place at school or nursery?” is Yes, “What support is in place?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Does the child take any medication?” is Yes, “Medication and doses” becomes mandatory before the form can be sent.
- All 4 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
About this template
Paediatric intake covers ground adult forms do not, and it is completed by someone answering on another person's behalf. This three-page form is written for a parent or carer. The first page records the child, the adults who hold parental responsibility, who else may bring the child to appointments, and the school or nursery. The second covers birth and development: pregnancy and delivery in brief, birth weight, feeding as a baby, whether milestones came in the expected range and any concern raised by another professional, immunisations to date, and previous illness, surgery or admissions. The third page turns to now — the concern that prompted the appointment, how long it has been present, how it affects sleep, eating, school and play, current medication and allergies, and any support already in place through school or another service. It ends with consent from the adult with parental responsibility to assess and treat, recorded with their relationship and signature. Nothing in the form assesses development; it gives the clinician the parent's account before the child is seen.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — Child and family
- Child's full namerequired
- Child's date of birthrequired
- Parent or carer completing this formrequired
- Relationship to the childrequired
- Contact numberrequired
- Email addressrequired
- Home address
- Who else may bring the child to appointments?
- School or nursery
Page 2 — Birth and development
- Pregnancy and delivery, briefly
- Birth weight in kilograms
- How was the child fed as a baby?required
- Did milestones come at about the expected time?required
- Has any professional raised a concern about development?required
- Who raised it, and what was said?
- Are immunisations up to date?required
- Which ones are outstanding, and why?
- Previous illness, surgery or hospital stays
Page 3 — Now
- What would you like help with?required
- How long has it been going on?required
- What is it affecting?required
- Does the child take any medication?required
- Medication and doses
- Allergies and what happens on exposure
- Is support already in place at school or nursery?required
- What support is in place?
- Consentrequired
- Signaturerequired
28 questions in total.
Example of a completed paediatric intake form
A sample intake showing how a parent describes their child's history and current concern before a first appointment.
- Child's full name
- Mia Chen
- Child's date of birth
- 19/05/2019
- Parent or carer completing this form
- Wei Chen
- Relationship to the child
- Mother
- Did milestones come at about the expected time?
- Yes
- Are immunisations up to date?
- Yes
- What would you like help with?
- Frequent coughing at night for the last week
- Does the child take any medication?
- No
- What is it affecting?
- Sleep
Sample data — no real people, addresses or records are shown.
How the form changes as it's filled in
This template ships with 4 conditional rules, grouped into 4 behaviours driven by 4 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Has any professional raised a concern about development?”
- Makes answers required
If “Has any professional raised a concern about development?” is Yes, “Who raised it, and what was said?” becomes required before the form can be submitted.
Driven by “Are immunisations up to date?”
- Makes answers required
If “Are immunisations up to date?” is No, “Which ones are outstanding, and why?” becomes required before the form can be submitted.
Driven by “Is support already in place at school or nursery?”
- Makes answers required
If “Is support already in place at school or nursery?” is Yes, “What support is in place?” becomes required before the form can be submitted.
Driven by “Does the child take any medication?”
- Makes answers required
If “Does the child take any medication?” is Yes, “Medication and doses” becomes required before the form can be submitted.
Set it up step by step
- 1
Ask who may bring the child
Naming the adults who can attend prevents an appointment being turned away and prevents one being given to someone who should not have it.
- 2
Keep the birth section short
A few lines about pregnancy and delivery is enough for most appointments; a full obstetric history belongs elsewhere.
- 3
Ask what the concern affects
Sleep, eating, school and play give a clinician the functional picture that a description of symptoms alone does not.
- 4
Take consent from the right adult
The consent question asks about parental responsibility explicitly, so record relationship rather than assuming the accompanying adult holds it.
Mistakes to avoid
- Using an adult intake form for children and missing development, immunisation and school context entirely.
- Accepting consent from whoever brought the child without recording their relationship or authority.
- Asking about milestones with no space for the parent to describe what they noticed.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Read the intake before the appointment, flag outstanding immunisations and any professional concern raised, and confirm who holds parental responsibility on the record.
Works in both layouts
Forms that overlap this one
These pages cover the same subject ground as the pediatric intake form, matched on the words people actually search for.
Patient History Form
clinicclinicalclinicianfamilyhealth
Patient Intake Questionnaire
clinicclinicalcliniciancurrenthealth
Quick Patient Registration
clinicclinicalcompletedconsenthealth
Eye Exam Intake Form
clinicclinicalcurrenthealthhistory
Chiropractic Intake Form
clinicclinicalconsenthealthhistory
Dermatology Patient Intake Form
clinicclinicalcurrenthealthhistory
Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
Who should complete this form?
An adult with parental responsibility, because the last page records their consent. Where another adult brings the child, name them in the attendance question instead.
Is it suitable for teenagers?
Older children may want to answer for themselves, and many services take a separate account from the young person. Use the Patient Intake Questionnaire alongside it in that case.
Why ask about school support?
Because it tells you what has already been tried and who else is involved, which changes both the assessment and who should receive a copy of any plan.
Does it assess development?
No. It records what the parent reports and what other professionals have said. Any developmental assessment is a clinical activity, not a form output.
Is the Pediatric Intake Form template free to use?
Yes. You can preview and test Pediatric Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Pediatric Intake Form template ask for?
It asks 28 questions across 3 pages, 17 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Pediatric Intake Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
4 conditional rules ship with the template: Features conditional validation: if “Has any professional raised a concern about development?” is Yes, “Who raised it, and what was said?” becomes mandatory before the form can be sent. Features conditional validation: if “Are immunisations up to date?” is No, “Which ones are outstanding, and why?” becomes mandatory before the form can be sent. Features conditional validation: if “Is support already in place at school or nursery?” is Yes, “What support is in place?” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Pediatric Intake Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Pediatric Intake Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Is the signature on this form legally usable?
The template captures a drawn signature and stores it with the submission, along with the timestamp, so you keep evidence of who agreed and when. Whether that is sufficient depends on your jurisdiction and the agreement itself.
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