PEDIATRIC NEW PATIENT INFORMATION
Date: ______
PATIENT INFORMATION
Child’s Name: ______Child’s Nickname: ______
Reason for Visit: ______
Sex: M / F Date of Birth: ______Age: ______Child’s SS #: ______
Child’s Home Phone #: ______
Child’s Home Address: ______
Who may we thank for referring you? ______
FAMILY INFORMATION
Mother’s Name: ______Mother’s SS #: ______
Father’s Name: ______Father’s SS #: ______
Mother’s Phone: ______WORK / CELL / HOME
Father’s Phone: ______WORK / CELL / HOME
Parent’s Marital Status: Married ____ Single ____ Divorced ____ Widowed ____
List Ages of Other Children in Family: ______
CONSENT TO TREAT
Being the parent or legal guardian of this child, I hereby authorize this office and its doctors to examine and
administer care to my son / daughter named ______as the
examining / treating doctor deems necessary .
I understand and agree that I am personally responsible for payment of all fees charged by this office for such care.
Parent’s Name: ______Signature: ______
Date: ______Witnessed By:______
Pre-School Child History
3 years to 5 years
Today’s Date: ______Child’s Name: ______
Sex: M F Date of Birth: ______Age: ______
Reason for Today’s Visit ______
The following questions are designed to help the doctor provide a detailed evaluation of your child.
Y / N Does your child ever complain of pain or discomfort? If yes, when did this occur?______
Was onset: Sudden_____ or Gradual_____ Is problem Constant _____ or Intermittent _____
Y / N Has your child ever had this problem before? ______
Y / N Has your child previously been treated for his problem before? By whom? ______
Y / N Has your child previously had chiropractic care? Previous chiropractor ______
Health History
Y / N Does your child ever complain of back or neck problems? ______
Y / N Does your child ever complain of pains in the legs or arms? ______
Y / N Does your child ever complain of headaches? ______
Y / N Has your child had asthma? ______
Y / N Is your child allergic to anything?______
Y / N Are there any smokers in the child’s home? ______
Y / N Has your child had any earaches? At what age did the child’s first earache occur? ______
How frequently do your child’s earaches usually occur? ______
In which ear do your child’s earaches usually occur? Right_____ Left _____ Both ______
Y / N Is your child currently taking any prescribed medications?______
Please list any other illness that have been a concern for your child ______
Please list any surgeries’ your child has had ______
Y / N Do you have any other concerns about your child’s health? ______
Trauma
Y / N Has your child had any recent falls or trauma? ______
Describe the trauma and date it occurred ______
Y / N Has your child ever fallen from a bicycle, skateboard, scooter, rollerblades or similar? ______
Y / N Has your child ever fallen down stairs or fallen from a significant height? ______
Y / N Has your child ever been in a motor vehicle collision or near-miss?______
Y / N Has your child ever had a bone fracture or joint dislocation? ______
Y / N Has your child had any other trauma or injuries?______
Y / N Does your child ever bang his/her head repeatedly against a wall, bed, or other object? ______
Nutrition
Y / N Do you have any concerns about your child’s diet? ______
Y / N Does your child have any food allergies?______
Y / N Does your child have any persistent or intermittent occurring skin rashes?______
Y / N Does your child take vitamin supplements?______
Y / N Does your child eliminate stools each day? ______
For how many months was your child breast fed? ______
What does your child usually eat for Breakfast? ______
What does your child usually eat for Lunch?______
What does your child usually eat for Dinner?______
What does your child usually eat for snacks?______
How much cow’s milk does your child drink each day? ______
What is your child’s’ favorite food?______
What type of fast foods does your child like to eat?______
APPOINTMENT REMINDERS
As a convenience to our patients we offer three options for your appointment reminders.
**Please choose only one option**
- OR -
- OR -
In addition, we will mail any written communication to the address you specified on your intake form, unless you request otherwise. Email communication is also for occasional news, special events, and office promotions. (HIPPA laws do not allow us to give your email or address to third parties). If you wish not to receive our emails, there is a removal button at the bottom of each email that will immediately remove you from future mailings.
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Patient Signature Date