Child's Name *

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Gender

Male

Female

Parent/Guardian *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Phone

(###)

###

####

Pediatrician

First Name

Last Name

How did you hear about our office?

Family

Friend

Website

Google

Facebook

Instagram

Other

Whom may we thank for referring you to our office?

First Name

Last Name

Reason for visit *

Wellness and improved health/funciton (of my child)

Health concern (for my child)

Date of Onset (chief complaint)

MM

DD

YYYY

Onset of (chief complaint)

Sudden

Gradual

Associated with an event

Duration of problem or episode:

Minutes

Hours

Days

Months

Years

Pattern of Problem

Constant

Intermittent

Occasional

Cyclical

Hospital/Birthing Center

Home

Hospital

Birthing Center

Was the birth assisted?

Yes

No

If assisted, how?

Forceps

Vacuum Extraction

C-section

Induced Labor

Were medications administered to mother during birth process?

Yes

No

Was it a normal birth?

Yes

No

Was the infant alert and responsive within 12 hours of the delivery?

Yes

No

Do his/her sleep patterns seem normal?

Yes

No

Do the child's sibling(s) have any health challenges?

Yes

No

During pregnancy did mom

Smoke

Drink alcohol

Take vitamins/supplements

During pregnancy did mom take drugs?

Yes

No

During pregnancy did mom become ill?

Yes

No

During pregnancy did mom receive ultrasounds?

Yes

No

During pregnancy did mom receive invasive procedures (ex: amniocentesis, CVS)?

Yes

No

Was your child breast fed?

Yes

No

Was cow's milk introduced?

Yes

No

Have solid foods been introduced?

Yes

No

Did your child receive vaccinations?

Yes

No

Did your child have a reaction to the vaccination(s)?

Yes

No

Has your child been on antibiotics?

Yes

No

Any pets at home?

Yes

No

Any smokers in the house?

Yes

No

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

Does your child have difficulties sleeping (ex: night terrors, sleep walking)?

Yes

No

Does your child go to daycare?

Yes

No

Any evidence of trauma during birth?

Bruises

Odd shaped head

Stuck in birth canal

Fast and/or excessively long birth

Respiratory Depression

Cord around neck

Other

Any falls/accidents during pregnancy?

Yes

No

Has the child had any major falls since birth?

Yes

No

Any hospitalizations for child?

Yes

No

Does your child play sports?

Yes

No

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.