Child’s Full Name:
Child’s Age:
Guardian’s Full Name: As it appears on your ID, Insurance card or medical record
What is your email address? *We'll use this to keep you up to date with office news and announcements
What is your phone number? *Please enter the best available phone number to reach you.
What is your complete home address? *Street number, City, State, and Zip Code
What is your date of birth?
Guardian's Age:
Guradian's Sex: MaleFemale
Have you or your child ever had chiropractic care before? YesNo
If yes, please tell us the doctor’s name
Is this appointment related to an accident or trauma? YesNo
Is your child receiving care form other health professionals? YesNo
If yes, please name them and their specialty
Who's your family’s primary care physician?
Please list any drugs or medications your child is taking
Please list any vitamins/herbs/homeopathics/other your child is taking
Please list any allergies your child has
What health concern brings your child to our office?
When did symptoms first begin?
How did it start? SuddenGradualPost-injury
Is this condition: Getting worseImprovingIntermittentConstantNot sure
What makes the problem better?
What makes the problem worse?
Has your child had a similar condition? YesNo
Please explain:
Has your child had treatment for this problem before? YesNo
Does your child eat well? YesNo
Does your child have regular bowel/bladder movements? YesNo
Has your child ever been checked for vertebral subluxation? YesNoNot Sure
Child’s Birth was at: At homeAt a birthing centerAt a hospital
My obstetrician/midwife/family physician was
Child’s birth was: Natural Vaginal (No medications or interventions)Vaginal with intervention
If vaginal with intervention, please select all that apply: InductionPain medicationEpiduralEpisiotomyVacuum extractionForceps
C-section: ScheduledEmergencyNo C-Section
Please list reasons for any interventions/complications
At what age did your child:
Respond to sound
Follow an object
Hold head up
Sit alone
Teethe
Crawl
Walk
Hospitalization/Surgical History: please list all surgeries and hospitalizations, including the year
Please list any major injuries, accidents, falls, and/or fractures your child sustained in his /her lifetime
Is/was your child breastfed? YesNo
If yes, for how long?
At what age was formula introduced?
What type?
At what age was cow’s milk introduced?
At what age did solid foods began?
Please list any food or drink intolerance:
Did mother smoke during pregnancy? YesNo
Did mother drink alcohol during pregnancy? YesNo
Any illness of mother during pregnancy? YesNo
If yes, please explain, including treatments:
List any drugs/medications, including over the counter, taken during pregnancy
List any supplements taken during pregnancy
Any pets at home? YesNo
Any smokers at home? YesNo
Has your child received any vaccinations? YesNo
If yes, any negative reactions?
Has your child received any antibiotics? YesNo
If yes, how many times and for what reason:
Any difficulty with breastfeeding? YesNo
If yes, please explain:
Any behavioral problems? YesNo
Any night terrors, sleepwalking, or difficulty sleeping? YesNo
Age child began daycare:
Average number of hours of TV your child watches per week
Are you seeking chiropractic for: Health maintenance/optimizationHealth problemsSelect all that apply.
Are there other health concerns or anything else you'd like us to know about your child?
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