Atlas Chiropractic _ Patient Intake Form _ PEDIA Logo

  • PEDIATRIC HISTORY FORM

  • It is a pleasure to welcome you to our family of happy and healthy chiropractic practice members. Please let us know if there is any way we can make you and your family feel more comfortable. Many types of stressors (physical, mental, and chemical) can interfere with your child’s growing brains, spine and overall nervous system. To help us serve you better, please complete the following information. We look forward to working with you to build better health for your family.

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  • Prenatal History

  • FEEDING HISTORY

  • Developmental History

    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).
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  • According to the National Safety Council, approximately 50% of children fall head first from a high place during their first year of life (i.e. a bed, changing table, down stairs)

  • Lifestyle

  • Clear
  • Should be Empty: