Pediatric Intake Form Patient Information Child’s Name Parent(s)/Guardian(s) Name Address City State Zip Home Phone Work Phone Cell Phone Is it okay to contact you at work? Yes No E-mail Child’s Social Security # Birthdate Age Have your or your child ever had chiropractic care before? Yes No If yes, please tell us the doctor’s name Were you pleased with your care? Yes No How did you find out about our office? Is this appointment related to an auto accident? If this injury is related to an auto accident, please fill out the Auto Accident Questionnaire. Yes No Is your child receiving care from other health professionals? Yes No If yes, please name them and their specialty Who is your family’s primary care physician? Please list any drugs or medications your child is taking Please list any vitamins/herbs/homeopathics/other your child is taking Please list any allergies your child has Current Health What health condition brings your child to our office? When did the symptoms first begin? How did the problem start? Suddenly Gradually Post-Injury Is this condition Getting Worse Improving Intermittent Constant Not Sure What makes the problem better? What makes the problem worse? Has your child ever had a similar condition? Yes No Please explain Has your child been treated for this problem before? Yes No Please explain Does your child eat well? Yes No Does your child eat well? Yes No Does your child have regular bowel/bladder movements? Yes No Has your child ever been checked for vertebral subluxations? Yes No Don’t Know Health History Child’s birth was At home At a birthing center At a hospital My obstetrician/midwife/family physician was Child’s birth was Natural vaginal (no mediciations/interventions) Vaginal with interventions Induction Pain medication Epidural Episiotomy Vacuum extraction Forceps other C-section Scheduled Emergency Please list reasons for any interventions/complications Child’s birth weight Child’s birth height Current weight Current height APGAr score at birth APGAr score after 5 minutes Growth & Development Was your child alert and responsive within 12 hours of delivery? Yes No If no, please explain At what age did the child: respond to sound Follow an object Hold head up Vocalize Sit alone teethe Crawl Walk Patient/Hospitialization/Surgical history (please list below all surgeries and hospitalizations, including the year) Is/was your child breastfed?YesNo If yes, how long? Formula introduced at age What type? Introduction of cow’s milk at age Began solid foods at age Please list any foods/juice intolerance Did mother smoke during pregnancy?YesNo Did mother drink alcohol during pregnancy?YesNo Any illness of mother during pregnancy?YesNo If yes, please explain including treatment/medications/supplements List any drugs/medications (including over the counter) taken during pregnancy List any supplements taken during pregnancy Any exposures to ultrasound?YesNo If so, how many and what was the medical reason? Any pets at home?YesNo Any smokers at home?YesNo Has child received any vaccinations?YesNo If yes, which ones and list any reactions Has child received any antibiotics?YesNo If yes, how many times and list reason Any difficulty with breastfeeding?YesNo If yes, please explain Any difficulty with bonding?YesNo If yes, please explain Any behavioral problems?YesNo If yes, please explain Any night terrors, sleepwalking or difficulty sleeping?YesNo If yes, please explain Age child began daycare Average number of hours of TV per week Does your child seem normal for their age?YesNo If no, please explain Family History Review Check those involving immediate family and add identification: M=Mother; F=Father; S=Siblings; G=Grandparents Cancer, type MFSG Depression MFSG Diabetes MFSG Back Problems MFSG Heart Disease MFSG Liver Disease MFSG High Blood Pressure MFSG High Cholesterol MFSG Lung Problems MFSG Scoliosis MFSG Neck Problems MFSG Osteoporosis MFSG Seizures MFSG Osteoarthritis MFSG Rheumatoid Arthritis MFSG Other Do You Know About Chiropractic Do you know what a subluxation is?YesNo Do any of your friends or relatives see a chiropractor?YesNo If yes, do they use chiropractic forHealth maintenance/optimizationHealth problemsBoth Are you seeking chiropractic forHealth maintenance/optimizationHealth problemsBoth What would you like to gain from chiropractic care? Are there other health concerns or anything else you’d like us to know about your child?