4LK Healthcare – Well Visit Intake Form

Patient & Guardian Information

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Contact Phone Number *

Please enter a valid phone number (digits only).

Responsible Parent/Guardian Email Address *

Please enter a valid email address.

Consent to be contacted by Four Lucky Kids *

Yes No

Well Visit – System Selection

Please select any of the following systems or health areas you would like to discuss or provide updates on for today's Well Visit:

Development / School / Behavioral Concerns Medications & Allergies Infectious Disease / Fever / Travel Skin / Rash Respiratory / Lungs Cardiovascular / Heart Gastroenterology / GI Neurological / Headache / Seizure Musculoskeletal / Joint Pain

Development / School / Behavioral Concerns

Any concerns since the last visit?

Any concerns with development?

Any concerns with behavior?

Any concerns with school?

Any concerns with sleep?

Any concerns with diet?

Medications & Allergies

Is the patient taking any daily medications, vitamins, or supplements?

Yes No

Please list all medications, dosage, and frequency:

Any known allergies?

Yes No

Please list all allergies and the reaction they cause:

Infectious Disease / Fever / Travel

Has the patient had any fevers recently?

Yes No

How high was the fever?

How was the temperature taken?

Has anyone around the patient been sick recently?

Yes No

Please describe the illness of those around the patient:

Any recent travel?

Yes No

Where did the patient travel? Please state where in the US or country (international):

Does the patient have any pets at home?

Yes No

What types of pets/animals?

Skin / Rash

Does the patient have a rash or skin concern?

Yes No

How long has the rash been present?

Describe the rash (location, itchy, blanches, etc.):

Does the patient have any new moles or birthmarks?

Yes No

Please describe the location and appearance:

Respiratory / Lungs

Does the patient have chronic congestion or runny nose?

Yes No

Does the patient have a cough?

Yes No

Is the cough productive?

Yes No

What does the product look like?

Does the patient experience shortness of breath?

Yes No

Does it occur during exercise or at rest?

Does the patient wheeze?

Yes No

When does the patient have wheezing?

Cardiovascular / Heart

Does the patient ever have chest pain?

Yes No

Does it happen during exercise?

Yes No Unsure

Has the patient ever fainted or felt like they were going to faint?

Yes No

What was the patient doing prior?

Does the patient have heart palpitations (racing heart)?

Yes No

Family History Screening

Any family history of sudden death before age 50?

Yes No

Any family history of unexplained drowning?

Yes No

Any family history of unexplained car accident?

Yes No

Any family history of congenital or childhood cardiovascular disease?

Yes No

Please explain the disease and relationship:

Gastroenterology / GI

Does the patient have frequent stomach aches?

Yes No

Any issues with nausea or vomiting?

Yes No

When does it occur? (e.g., related to meals, after coughing)

Describe the patient's bowel movements:

How many bowel movements per day?

Any blood in the stool?

Yes No

Neurological / Headache / Seizure

Does the patient have frequent headaches?

Yes No

Please describe the headache and what makes it better:

Is the headache worse in the morning or evening?

In the morning In the evening Unsure

Any history of seizures?

Yes No

Describe the seizure activity:

How many seizures a day is the patient having?

Does the patient currently have a neurologist?

Yes No

Any history of concussions or hitting their head?

Yes No

Is the patient having any visual changes?

Yes No

Musculoskeletal / Joint Pain

Any bone, joint, or muscle pain?

Yes No

Describe the location and type of pain (sharp, dull, achy):

Can the patient bear weight on the affected area?

Yes No

Does the patient have any difficulty with walking or coordination?

Yes No