Pediatric Patient Form

Parent/Guardian:*

First

Last

Email*

Home Phone*

Cell Phone*

Child's Name*

First

Last

Today's Date

Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Birth Date*

day

/

month

/

year

Sex*

Known Allergies:*

Reason for pursuing care:

If problem, describe:

Other doctors seen for this condition?

yes

no

Doctor's name and prior treatment:

List any other health problems:*

Family history:

Other Conditions:

Previous Chiropractic Care?*

yes

no

Last visit:

# of Doses of ANTIBIOTICS your child has taken in the [past 6 months]:

# of Doses of ANTIBIOTICS your child has taken [total lifetime]:

Present prescription drugs/dosage:

Past prescription drugs/dosage:

Over the counter drugs (Tylenol, cough syrup, laxatives, etc.)

INSURANCE INFORMATION

Name of Insurance Company

Insurance Member ID

Provider Services Phone Number

Please upload a picture of the front of your insurance card

Please upload a picture of the back of your insurance card

Prenatal History

Complications during pregnancy/delivery?

yes

no

If yes, explain:

Medications taken during pregnancy/delivery?

yes

no

If taken, list:

Cigarette/Alcohol use during pregnancy?

yes

no

Birth Route (check all that apply):

Vaginal

Caesarian Section

Forceps

Vacuum Extraction

If Caesarian Section, was it:

Emergency

Planned

Genetic disorders or disabilites

yes

no

List:

Birth weight:

Birth Length:

APGAR Scores:

Developmental History

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).

Please answer to the best of your ability! At what age was your child able to:

Respond to Stimuli:

Cross Crawl:

Stand Alone:

Respond to Visual Stimuli:

Hold Head Up:

Walk Alone:

Sit up:

According to the National Safety Council, approximately 50% of children fall head first from a high place during their first year of life (i.e. a bed, changing table, down stairs)

Has your child been involved in any sports?

Yes

No

List sports:

Did your child have a fall similar to what was described above?

Yes

No

Explain the fall:

Have your child been seen by a physician on an emergency basis?

yes

no

Explain:

Other traumas not described above?

Lifestyle

Please tell us more about your little one!

Child's hobbies or interests:

Is there anything else you would like to know about your child?

INSURANCE INFORMATION

Prenatal History

Developmental History

Lifestyle

Having issues with the online form? Download the PDF to electronically fill out or print off to save you time upon your first appointment.