Pediatric History Form

Dear New Patient

It is a pleasure to welcome you to our family of healthy and happy chiropractic patients. Please let us know if there is any way we can make
you and your family feel more comfortable. To help us serve you better, please complete the following information. We look forward to working
 with you to build better health for your family.
Patient Name: SS#
Sex: M □ F □ Weight: Height: Birth Date: / /
Address: City:
State: Zip: Home Ph #:
Referred by:
Name of Parents/Guardians: Parent/s Work Ph #:
Purpose for contacting us?
Have other Doctors been seen for this condition? □ No □ Yes If yes, Doctors’ Names and Prior Treatments:
 
Other Health Problems?
Check any of the following conditions your child has suffered from during the past six months:
□ Ear Infections □ Scoliosis □ Seizures □ Chronic Colds □ Headaches
□ Asthma / Allergies □ Digestive Problems □ ADD / ADHD □ Recurring Fevers □ Growing/back pains
□ Colic □ Bed Wetting □ Car Accident □ Temper Tantrums □ Other
Family History:
Previous Chiropractor:
Date of last visit: / / Reason:
Name of Pediatrician:
Date of last visit: / / Reason:
Are you satisfied with the care your child has received there? □ No □ Yes
Number of Antibiotics your child has taken in:
Past 6 months: Total during his/her lifetime?
Number of doses of other prescription medications your child has taken in:
Past 6 months: Total during his/her lifetime?
Vaccination History:
Prenatal History:
Name of Obstetrician / Midwife:
Complications during pregnancy: □ No □ Yes List:
Ultrasounds during pregnancy: □ No □ Yes List:
Medications during pregnancy / delivery: □ No □ Yes List:
Cigarette / alcohol use during pregnancy: □ No □ Yes

 

Location of Birth: □ Hospital □ Birthing Center □ Home
Birth intervention: □ Forceps □ Vacuum extraction □ Caesarian:- □ Emergency □ Planned
Complications during delivery: □ No □ Yes List:
Genetic disorders or disabilities: □ No □ Yes List:
Birth weight:   Birth Length: APGAR scores:   APGAR Scores:
Feeding history:
Breast fed: □ No □ Yes How long:   Formula fed: □ No □ Yes How long:
Introduced to solids at: months   Cows milk at: months
Food/juice allergies or intolerances: □ No □ Yes List:
Developmental history:
During the following times your child’s spine is most vulnerable to stress and should routinely be checked by a doctor of chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference). At what age was your child able to:
Respond to sound:   Respond to visual stimuli:
Hold head up:   Sit up:
Cross crawl:   Stand Alone:
Walk alone:
According to the National Safety Council, approximately 50% of all children fall head first from a high place during their first year of life (i.e. a bed, changing table, down stairs etc.). Was this the case with your child? □ No □ Yes
Is/has your child been involved in any high impact or contact type sports (i.e. soccer, football, gymnastics, baseball, cheerleading, martial
arts etc.)? □ No □ Yes List:
 
Has your child ever been involved in a car accident? □ No □ Yes When?
Has your child been seen on an emergency basis? □ No □ Yes When/why?
 
Other traumas not described above? □ No □ Yes List:
 
Prior surgery? □ No □ Yes List:
 
Menarche: □ No □ Yes Age:
Childhood diseases:
Chicken Pox: □ No □ Yes Age:   Mumps: □ No □ Yes Age:
Rubella: □ No □ Yes Age:   Whooping cough: □ No □ Yes Age:
Rubeola: □ No □ Yes Age:   Other: □ No □ Yes Age:

We are here to serve you, and encourage you to ask questions. Your participation is vital and will help determine your results.

Authorization for care of a minor
I hereby authorize this office and its doctors to administer care to my son/daughter as they deem necessary. I clearly understand and agree that I am personally responsible for payment of all fees charged by this office.

Name of Insurance Company: Policy #
Signed: Witnessed: Date: / /