Confidential Pediatric/Child Patient Information  

Date:                

First Name:      Last Name:           

Last Four Digits of Social Security #:                   Home Phone:

Age:     Birth Date:     Sex:  Male (M) Female (F)   Weight:    Height:

Names of Parents / Guardians:           Work Phone:

E-mail:

Who referred you to my office?:

CONSENT TO TREAT A MINOR

I hereby request and authorize this office and its doctor to perform diagnostic test and render chiropractic care as she deems necessary, to my minor child: . As of this date, I have the legal right to select and authorize health care services for the minor child named above.

Parent / Guardian Printed Name:

Purpose of visit / specific concern:

Other Doctors seen for this condition:    Yes    No   Dr.’s Name:

Treatment:

Previous Chiropractor:                    Last Visit:

Reason for Care:

Other Health Problems:

Name of Pediatrician:                      Last Visit:

Number of Doses of Antibiotics your child has taken: Last 6 months      Lifetime

Number of Doses of other Prescription Medication your child has taken: Last 6 months      Lifetime

Vaccination History:

PRENATAL HISTORY

Name of Obstetrician / Midwife:

Complications During Pregnancy?    Yes     No    List:

Complications During Delivery?       Yes     No    List:

Ultrasounds During Pregnancy?       Yes     No    Number:

Medications During Pregnancy?      Yes     No    List:

Cigarette /Alcohol use During Pregnancy?      Yes     No     Describe:

Location of Birth:    Hospital       Birthing Center       Home

Birth Intervention:      Forceps       Vacuum Extraction       Caesarian Section

Birth Weight:      Birth Height:

FEEDING HISTORY:

Breastfed:  Yes No    How long?      Formula fed:  Yes No    How long?   

Introduced:   Solids at months      Cows milk at months

Food / Juice Allergies or Intolerances:    Yes     No     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 (spinal nerve interference). At what age was your child able to:

Respond to sound       Hold head up       Sit up

Respond to visual stimuli      Cross crawl       Stand alone

Walk alone

According to the National Safety Council, approximately 50% of children fall from a high place during their first year of life (e.g. a bed, changing table, down stairs etc). Was this the case with you child?

Yes     No    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.)?  Yes No  List:

Has your child ever been involved in a car accident?  Yes  No  List:

Has your child been seen on an emergency basis?      Yes  No  Reason:

Other traumas not described above?    Yes   No   List:

Prior Surgery: Yes No   List:    Menarche: Yes   No  Age: