Pediatric Form

CONFIDENTIAL PATIENT INFORMATION

Child First Name

Child Last Name

Patient Guardian First Name

Patient Guardian Last Name

Street Address

City

State / Province

Postal / Zip Code

Cell Phone

Other Phone

Child sex

Male Female

Child's SS #

Birth Date

Age

How did you hear about us?

Weight

Height

Who is you primary care physician?

Is your child receiving care from any other health professional?

Yes No

If yes, please name them and their specialty:

Please list any drugs/medication/vitamins/herbs/other that your child is taking:

What health condition(s) bring your child to be evaluated by a chiropractor?

When did the condition first begin?

How did the problem start?

Suddenly Gradually Post Injury

Has your child ever received care for this condition before?

Yes No

If yes, please explain:

Is this condition:

Getting Worse Improving Intermittent Constant Unsure

What makes the problem better?

What makes the problem worse?

HEALTH GOALS FOR YOUR CHILD

What are your top three health goals for your child:

What would you like to gain from chiropractic care?

Resolve existing condition Overall wellness Both

Have you ever visited a chiropractor?

Yes No

If yes, what is their name?

What is their specialty?

Pain Relief Physical Therapy & Rehab Nutritional

PREGNANCY & FERTILITY HISTORY

Please tell us about your pregnancy

Any fertility issue?

Yes No

If yes, please explain:

Did mother smoke?

Yes No

If yes, how many per week?

Did mother drink?

Yes No

If yes, how many per week?

Did mother exercise?

Yes No

If yes, please explain:

Was mother ill?

Yes No

If yes, please explain:

Any ultrasounds?

Yes No

If yes, please explain:

Please explain notable episodes of mental or physical stress during your pregnancy:

Please explain any other concerns or notable remarks about your child's conception or pregnancy:

LABOR & DELIVERY HISTORY

Child's birth was:

Natural Vaginal Birth Schedule C-section Emergency C-section

At how many week's was your child born?

Child birth was:

At home At a birthing center At a hospital

Doctor/Obstetrician's Name:

Please check any applicable interventions or compilations:

Breech Induction Pain meds Epidural Episiotomy Forceps

Child's birth weight:

Child's birth height:

APGAR score at birth:

APGAR score after 5minutes:

GROWTH & DEVELOPMENT HISTORY

Is/was your child breastfed?

Yes No

Did they ever use formula?

Yes No

If yes, at what age?

If yes, what type?

Did/does your child ever suffer from colic, reflux or constipation as an infant?

Yes No

If yes, please explain:

Did/does your child frequently arch their neck/back, feel stiff, or bang their head?

Yes No

If yes, please explain:

At what age did the child:

Respond to sound:

Follow an object:

Hold their head-up:

Vocalize:

Teethe:

Sit alone:

Crawl:

Walk:

Begin cow's milk:

Begin solid food:

Please list any food intolerance or allergies, and when they began?

Please list your child's hospitalization and surgical history, including the year:

Please list any major injuries, accidents, falls and/or fracture your child has sustained in his/her life time, including the year:

Have you chosen to vaccinate your child?

No Yes, on a delayed or selective schedule Yes, on schedule

If yes, please list any vaccination reactions:

Has your child received aby antibiotics?

Yes No

If yes, how many times and list reason:

Night terrors or difficulty sleeping?

Yes No

If yes, please explain:

Behavioral, social or emotional issues?

Yes No

If yes, please explain:

How many hours per day does your child typically spend watching a TV, computer, tablet or phone?

How would you describe your child's diet?

Mostly whole, organic foods Pretty average High amount of processed foods

ACKNOLEDGMENT & CONSENT

Signature

Date

Patient Review of System

THE NERVOUS SYSTEM CONTROL AND COORDINATES ALL ORGANS AND STRUCTURES OF THE HUMAN BODY

Please check the corresponding boxes for each symptom or condition you have experienced - including both past and present

REGIONS Cervical

FUNCTIONS

Autonomic Nervous System
ENT Sysrem
VIsion, Balance & Coordination
Speech
Immune System
Digestive System
Nerve supply to Shoulders, Arns & Hands
Sympathetics Nucleus
Metabolism

SYMPTOMS

Colic & Excessive Crying

Past Present

Ear & sinus infections

Past Present

Allergies & Congestion

Past Present

Headaches & Migraines

Past Present

Vertigo & Dizziness

Past Present

Sore Throat & Strep

Past Present

Swollen Tonsils & Adenoids

Past Present

Visions & Hearing Issues

Past Present

Low Energy & Fatigue

Past Present

Difficulty Sleeping

Past Present

Pain Numbness & Tingling in Arms to Hand

Past Present

Epilepsy & Seizures

Past Present

Sensory & Spectrum

Past Present

ADD / ADHD

Past Present

Focus & Memory Issues

Past Present

TMJ / Jaw Pain

Past Present

Stiff Neck $ Shoulders

Past Present

Depression

Past Present

High Blood Pressure

Past Present

Poor Metabolism & Weight Control

Past Present

REGIONS Upper Thoracic

Function

Upper G.I.
Respiratory System
Cardiac Function

SYMPTOMS

Reflux / GERD

Past Present

Chronic Colds / Cough

Past Present

Asthma

Past Present

Bronchitis & Pneumonia

Past Present

Functional Heart Conditions

Past Present

REGIONS Mid Thoracic

FUNCTION

Major Digestive Center
Detox & Immunity

SYMPTOMS

Gallbladder Pain / Issues

Past Present

Jaundice

Past Present

Fever

Past Present

Indigestion / Heartburn

Past Present

Stomach pain & Ulcers

Past Present

Blood Sugar Problem

Past Present

REGIONS Lower Thoracic

FUNCTIONS

Stress Response
Filtration & Elimination
Gut & Digestion
Hormonal Control

SYMPTOMS

Behavior Issues

Past Present

Hyperactivity

Past Present

Chronic Fatigue

Past Present

Chronic Stress

Past Present

Allergies & Eczema

Past Present

Skin Conditions & Rash

Past Present

Kidney Problem

Past Present

Gas Pain & Bloating

Past Present

REGIONS Lumbar, Sacrum & Pelvis

FUNCTION

Lower G.I. (Absortion & Motility)
Gut-Immune System
Major Hormonal Control

SYMPTOMS

Constipation

Past Present

Chrohn's Colitis & IBS

Past Present

Diarrhea

Past Present

Bed-wetting

Past Present

Bladder & Urination Issues

Past Present

Cramps & Menstrual Issues

Past Present

Cysts & Endometriosis

Past Present

Infertility

Past Present

Impotency

Past Present

Hemorrhoids

Past Present

Hemorrhoids

Past Present

Sciatica & Radiating Pain

Past Present

Lumbopelvic / SI Joint Pain

Past Present

Hamstring Tightness

Past Present

Disc Degeneration

Past Present

Leg Weakness & Cramps

Past Present

Poor Circulation & Cold Feet

Past Present

Knee, Ankle & Foot Pain

Past Present

Weak Ankles & Arches

Past Present

Lower Back Pain

Past Present

Gluten Casein Intolerance

Past Present

Patient Name

Date

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