Chiropractic Solutions
4080 Tower Street. #1080
PO Box 5
St. Bonifacius, MN 55375
(952) 446-1212
C:\ChiroSolutions\Forms\Pediatric\Pediatric History Form.docx
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:______Date:______
Address: ______City/State:______Zip:______
Birth Date: ______Home Phone: ______Work Phone:______
Sex:_____Weight:_____Height:______Referred by:______
Names of Parents/Guardians:______
PURPOSE FOR CONTACTING US:
______
Other Doctors Seen for this Condition: _____N_____Y, 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 Digestive Problems 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:______
Number of Doses of Antibiotics Your Child has Taken:
During the Past Six Months:______, Total During His/Her Lifetime:______
Number of Doses of Other Prescription Medications Your Child has Taken:
During the Past Six Months:______, Total During His/Her Lifetime:______
List:______
Vaccination History:______
PRENATAL HISTORY
Complications During Pregnancy: _____N _____Y, List:______
Ultrasounds During Pregnancy: _____N _____Y, Number:______
Medications During Pregnancy/Delivery: _____N _____Y, List:______
Cigarette/Alcohol Use During Pregnancy: _____N _____Y
Location of Birth: _____Hospital _____Birthing Center _____Home
Birth Intervention: _____Forceps _____Vacuum Extraction _____Caesarian Section, Emergency or Planned?
Complications During Delivery? _____N _____Y, List:______
Genetic Disorders or Disabilities: _____N _____Y, List:______
Birth Weight: ______Birth Length: ______APGAR Scores: _____,______
FEEDING HISTORY
Breast Fed: _____N _____Y, How Long: ______
Formula Fed: _____N ____Y, How Long: ______Type:______
Introduced to Solids at: _____Months, Cows’ Milk at: _____Months
Food/Juice Allergies or Intolerances: _____N _____Y, 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 (spine nerve interference). At what age was your child able to:
_____Respond to Sound_____Hold Head Up_____Cross Crawl
_____Respond to Visual Stimuli_____Sit Up_____Stand Alone_____Walk Alone
Has your child ever fallen head first from a high place during their first year of life (such as a bed, changing table, down stairs, etc)? _____N _____Y, List:
______
Is/has your child been involved in any high impact or contact type sports (i.e. soccer, football, gymnastics, baseball, cheerleading, martial arts, etc.)? _____N _____Y, List:
______
Has Your Child Ever Been Involved in a Car Accident? _____N _____Y, List:______
Has Your Child Been Seen on an Emergency Bases? _____N _____Y, List:______
Other Traumas Not Described Above: _____N _____Y, List:______
Prior Surgery: _____N _____Y, List:______
Menarche: _____N _____Y, Age: _____
CHILDHOOD DISEASES
Chicken PoxN / Y, Age:_____MumpsN / Y, Age: _____
RubellaN / Y, Age:_____Whooping CoughN / Y, Age: _____
Rubeola N / Y, Age:_____Other ______N / Y, 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.
Signed:______Date:______Witnessed:______
C:\ChiroSolutions\Forms\Pediatric\Pediatric History Form.docx