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Lifelong Wellness Mary Jane DeWolfSmith, PhD, MA, LEFT License # 35490 NPI: 1306223789 610 D Street, Suite C, San Rafael, CA 949013708 4158272974Confidential CHILD INTAKE FORM Please print out, complete
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Start by entering the child's personal information such as name, date of birth, and gender.
02
Provide contact details including phone number and email address for the child's primary caregiver.
03
Specify any medical conditions or allergies that the child may have.
04
Indicate the child's current medications and provide dosage details if applicable.
05
Include information about the child's medical history, such as previous surgeries or hospitalizations.
06
Provide details about the child's immunization records and any relevant vaccinations.
07
Mention any psychological or behavioral concerns that the child may be experiencing.
08
Include information about the child's dietary preferences or restrictions.
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If applicable, provide information about the child's physical activity levels and exercise routines.
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Finally, review the filled-out form for accuracy and completeness before submitting it.

Who needs childintake form- lifelong wellness?

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Parents or legal guardians of children who are seeking lifelong wellness services for their child.
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The childintake form for lifelong wellness is a document used to gather information about a child's health, developmental history, and lifestyle to promote ongoing wellness and preventive care.
Parents or legal guardians of children typically are required to file the childintake form for lifelong wellness as part of healthcare assessments.
To fill out the childintake form for lifelong wellness, a parent or guardian should complete all required sections, providing accurate and comprehensive information about the child’s health, medical history, and lifestyle.
The purpose of the childintake form for lifelong wellness is to collect essential data that helps healthcare providers tailor wellness programs and interventions to promote optimal health outcomes for children.
The information that must be reported on the childintake form for lifelong wellness includes the child's personal details, medical history, family health history, lifestyle choices, and any current health concerns.
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