What is the pediatric patient intake form template?
Child patients come with questions adult forms don't ask: who the parents or guardians are, whether any court orders affect who can consent, how the birth went, whether vaccinations are up to date, and whether there are any developmental concerns.
This template covers all of it in five pages. A second guardian and custody arrangements are asked about directly, with follow-ups only when needed. Birth and development questions are mostly optional, so parents of older children aren't stuck on details they can't remember, while allergies, medications, immunizations and diagnosed conditions are always answered.
Each registration is filed as a signed PDF in the vault folder you choose, with immunization records and custody documents attached.
- Best for
- Pediatric practices, family clinics and children's therapy services
- Filled in by
- A parent or legal guardian
- Time to complete
- About 10 minutes
- Includes
- Guardian and custody logic, birth and development history, immunization upload, allergies and medications, family history, consent
Who uses a pediatric patient intake form?
- Registering newborns with a pediatrician
- Families moving to a new area and changing clinics
- Children's therapy services — speech, occupational or physiotherapy — taking on a new child
- Foster carers registering a child placed with them
- Clinics that need custody arrangements on record
- Replacing a clipboard in the waiting room with a form parents do at home
Questions on this pediatric patient intake form
43 questions over 5 pages · includes signature, file upload, conditional questions, multiple pages, consent checkbox.
1 About your child
- Child's full name*
- Name they like to be called
- Date of birth*
- Sex* Female · Male · Intersex / other · Prefer not to say
- School, nursery or daycare
- Languages spoken at home
- Previous doctor or clinic
2 Parents & guardians
- Parent or guardian's name*
- Relationship to the child* Mother · Father · Legal guardian · Foster parent · Grandparent · Other
- Mobile phone*
- Email*
- Home address*
- Is there a second parent or guardian?*
- Second parent or guardian's name* asked only when it applies
- Their relationship to the child* asked only when it applies Mother · Father · Legal guardian · Foster parent · Grandparent · Other
- Their phone* asked only when it applies
- Their email asked only when it applies
- Are there custody arrangements or court orders we should know about?*
- Please explain* asked only when it applies
- Copy of the order or agreement asked only when it applies
- Other adults who may bring your child to appointments
3 Birth & development
- Weeks of pregnancy at birth
- Birth weight
- Type of birth Vaginal birth · Planned caesarean · Emergency caesarean · Not known
- Did your child need special or intensive care after birth?
- What for, and for how long? asked only when it applies
- Do you have any concerns about your child's development?*
- Tell us more* asked only when it applies
4 Health
- Are your child's immunizations up to date?* Yes, up to date · Partly · Not vaccinated · Not sure
- Immunization record
- Anything we should know about vaccinations? asked only when it applies
- Does your child have any allergies?*
- Allergy and the reaction* asked only when it applies
- Does your child take any regular medication?*
- Medication, dose and how often* asked only when it applies
- Has your child been diagnosed with any of these?* Asthma · Eczema · Diabetes · Epilepsy or seizures · Heart condition · ADHD · Autism · Hearing or vision problems · None of these
- Hospital stays, operations or serious illnesses
- Family history — do close relatives have any of these? Asthma or allergies · Diabetes · Heart disease at a young age · A genetic or inherited condition · Mental health conditions
5 Consent
- Consent to care*
- Privacy*
- Accuracy*
- Parent or guardian signature*
- Date*
The pediatric patient intake form, page by page
1 About your child
The child's name, date of birth and sex are required. Preferred name, school or daycare, languages at home and previous doctor are optional.
2 Parents & guardians
The first parent or guardian's name, relationship, mobile, email and home address are required. If there's a second parent or guardian, their name, relationship to the child and phone are needed, and email is optional. A required question asks about custody arrangements or court orders; yes asks for an explanation and an optional copy of the order. Other adults who may bring the child can be listed.
3 Birth & development
Weeks of pregnancy at birth, birth weight, type of birth and any special or intensive care are optional. A required question asks about developmental concerns — speech, movement, hearing, vision, learning or behaviour — with details if yes.
4 Health
Immunization status is required, with an optional upload of the record and a notes box if not fully up to date. Allergies and regular medication are required yes/no questions with details if yes. A required checklist of diagnosed conditions (asthma, eczema, diabetes, epilepsy, heart conditions, ADHD, autism, hearing or vision problems, or none) is followed by optional hospital history and family history.
5 Consent
The parent or guardian confirms they may consent and agree to examination and treatment, agree to the use of the information, and confirm it's accurate. Signature and date complete it.
Make the template yours
- Add insurance or payment questions for your practice
- Adjust the immunization question to your country's schedule
- Add age-specific screening questions, such as feeding for infants
- Route intakes into a folder per family so siblings stay together
- Add your clinic's address and what to bring to the cover text
- Send it with appointment confirmations so it's done before the visit
Tips for a better pediatric patient intake form
- Check custody answers before the first visit so you know who can consent
- Ask parents to bring the physical immunization record even if they've uploaded a photo
- Flag allergy answers clearly in your own records
- Review developmental concerns at the first appointment, even if briefly
- Keep children's health records in a restricted folder
- Adapt the consent wording to your local rules on consent for minors — this is a starting template
Every response becomes a PDF in your vault
Each registration is filed as a signed PDF in your chosen vault folder, with immunization records and custody documents attached. The clinic is notified and the parent receives a copy.
Use the Responses table to prepare for new-patient visits, filter by immunization status or allergies, and export to CSV for your practice-management system.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Pediatric patient intake form: frequently asked questions
Is this pediatric patient intake template free to use?
Yes. It's one of FileIt's ready-made templates, and every FileIt account, including the free plan, includes the Forms app and its full library of templates.
Do parents need a FileIt account to fill it in?
No. Parents complete it from a link or emailed request without an account. Only the clinic needs one.
Can parents upload their child's immunization record?
Yes. They can upload up to three photos or PDFs of the record.
How does the form handle separated parents?
It asks for a second parent or guardian and directly about custody arrangements or court orders, with a place to explain and upload a copy.
Can I use it for teenagers?
Yes, though you may want to add questions for teens and adapt the consent to local rules on when young people can consent for themselves.
Is the consent wording ready to use?
It's a starting point. Adapt it to your practice and your local rules on consent and health privacy.