1st Place Chiropractic - PEDIATRIC INTAKE FORM

PEDIATRIC INTAKE FORM

Please complete the following information about the Patient (Child):
Child's Name*

First NameLast Name
Date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex*
Date of Birth*

MonthDayYear
Date
Age*
Height*
Weight*
Name of Parent/Guardian*

First NameLast Name
Email*
example@example.com
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Whom may we thank for your referral?

First NameLast Name

General Questions/ Prenatal History:
Birthing Intervention*

Normal VaginalForcepsCesareanSuction Cap or Vacuum
Is your child adopted?*
Problems during pregnancy:*
Problems during labor/delivery:*
Immunization history:*
Number of doses of antibiotics your child has taken during the past 6 months:*
Number of doses of antibiotics your child has taken during his/her lifetime:*
At what age, if ever, did this child suffer from the following childhood diseases?
Chickenpox
Mumps
Measles
Rubella
Rubeola
Whooping Cough
Other

Has this child ever sustained an injury playing organized sports? If yes, please explain:*
Has this child ever sustained injuries in an auto accident? If yes, please explain:*
Has this child ever broken/fractured any bones? If yes, please explain:*
Has this child ever received stiches not related to surgery? If yes, please explain:*
Other traumas not described above:*
Surgeries:*
Medications:*
Present history:*
Purpose of this appointment:*

AUTHORIZATION FOR CARE FOR MINOR
I hereby authorize this office and its doctor(s) to administer care as they so deem necessary to my son/daughter/ward (upon approval of guardian).
Signature*

Clear
Date

MonthDayYear
Date
I realize that I am responsible for all fees charged by this office and I agree to pay for all services provided. X-rays remain the property of this office.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

PEDIATRIC INTAKE FORM