Let’s work together Child's Name * First Name Last Name Child's Date of Birth * MM DD YYYY Sex * Male Female Parent/Guardian's Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian's Phone * (###) ### #### Parent/Guardian's Email * Pediatrician First Name Last Name How did you hear about our office? Family Friend Pediatrician Google Social Media Other Whom may we thank for referring you to the office? First Name Last Name Child's History Reason for visit * Wellness and improved health/function (of my child) Health challenge/concern (for my child) What are your chief concerns (your main reason for contacting our office), if any, with your child's health? Please list any other care your child has undergone with regards to this concern, including medication: Date of onset of health challenge/concern (if present) MM DD YYYY Onset of health challenge/concern (if present) Sudden Gradual Associated with an event Pattern of Problem Constant Intermittent (comes and goes) Duration of problem or episode(s) (if applicable) Minutes Hours Days Initiating Factors Aggravating Factors Relieving Factors Prior episodes or occurrence? How does the problem affect your child's body function and daily activities? Child's Birth Duration of Gestation (weeks pregnant) Hospital/Birthing Center * Home Hospital Birthing Center Was the birth assisted? * Yes No If assisted, how? Forceps Vacuum extraction C-section (caesarean) Induced labor Were medications administered to mother during birth process? Yes No If yes, what was given? Duration of labor (hours) Were there any complications (during labor/birth)? * Yes No If yes, what complications were experienced during labor/birth? Growth and Development APGAR (Appearance, Pulse, Grimace, Activity and Respiration) Score at time of birth? APGAR Score after 5 minutes? Birth weight and length Was the infant alert and responsive within 12 hours of the delivery? * Yes No If no, please explain At what age did your child: respond to sound? At what age did your child: follow an object? At what age did your child: hold head up? At what age did your child: vocalize? At what age did your child: sit alone? At what age did your child: teethe? At what age did your child: crawl? At what age did your child: walk? Do your child's sleep patterns seem normal? Yes No Family History Describe any health problems that exist on mother's side of the family (ex: cancer, diabetes): Describe any health problems that exist on father's side of the family (ex: cancer, diabetes): Do the child's sibling(s) have any health challenges? * Yes No No siblings If yes, please explain Environmental and Chemical Stressors During pregnancy did mom Smoke (cigarettes) Smoke (weed) Take edibles Illegal drugs During pregnancy did mom take any prescription drugs? * Yes No If yes, what? During pregnancy did mom take vitamins/supplements Yes No If yes, what? During pregnancy did mom become ill? * Yes No If yes, please explain: During pregnancy did mom receive ultrasounds? Yes No If yes, how many and why? During pregnancy did mom receive invasive procedures (ex: amniocentesis, chorionic villus sampling)? Yes No Any pets at home? Yes No If yes, what type of animals? Any smokers in the house? * Yes No Growth and Development Was your child breast fed? * Yes No Currently breast feeding If yes, for how long (weeks, months, years)? At what age was formula introduced? Brand of formula? Was cow's milk introduced? Yes No If yes, how old (in months/years)? Have solid foods been introduced? Yes No If yes, how old (months/years)? Did your child receive vaccinations? * Yes No If yes, which ones? Did your child have an adverse reaction to the vaccination(s)? * Yes No If yes, please explain Has your child been on antibiotics? * Yes No If yes, how many courses has the child had so far and why were they prescribed? Does your child have any allergies (please list)? Psychological Stressors Any difficulties lactating? * Yes No Any problems bonding? * Yes No Does your child seem normal to you? * Yes No Does the child have any behavioral problems * Yes No If yes, please explain Does your child have difficulties sleeping (ex: night terrors, sleep walking)? * Yes No If yes, please explain Does your child go to daycare? * Yes No If yes, from what age (months/years)? Average numbers of screen time (smart phone, tablet/iPad, TV) each week? Trauma Any evidence of trauma during birth? Bruises Odd shaped head Stuck in birth canal Fast or extremely long birth Respiratory depression Cord wrapped around neck Other If other, please explain Did mom have any falls/accidents/traumas during pregnancy? * Yes No If yes, please explain Has the child had any major falls since birth? * Yes No If yes, did the child need stitches or a cast? Please explain Any hospitalizations for child? Yes No If yes, please explain Does your child play sports? * Yes No What sport does he/she play? Age began participation (in sport)? Number of hours of participation (in sport)? Approximate weight of school back pack? Approximate hours spent at play per week? Informed Consent Chiropractic is a art, science, and philosophy which concerns itself with the relationship between the spinal structure and the health of the central nervous system. Any disturbance to the CNS will create sickness and disease. One such disturbance to the nervous system is known as a vertebral subluxation. If during the course of care we encounter a non-chiropractic issue we will refer you out to the appropriate health care provider. I have the right, as a patient/guardian, to be informed about the condition and the recommended care to be provided so that I can make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives. I have read and fully understand the above statements and therefore accept chiropractic care on this basis. By checking the box, I am consenting to care. Submit Thank you!
