• Pediatric New Patient Forms

    This form is for children ages 12 and under

  • Patient Information

  • Today's date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Date of Birth:*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Does the patient have any siblings?*

  • How can we help your child?

  • How did this begin?*
  • Please check boxes on any other areas you would like addressed:*
  • Was the mother under chiropractic care during pregnancy*
  • Has the patient received previous chiropractic care?*

  • Birth History

  • Location of birth:*
  • Did any of the following occur during delivery?*

  • Growth and Development

  • Has your child ever taken antibiotics?*
  • Has your child ever been hospitalized?*
  • Is this condition interfering with any of the following?
  • Does the patient have a positive self image?*
  • Does the patient get daily exericse?*
  • Please check all that apply:*
  • Select the food most commonly in your child's diet:*
  • Has your child received all recommended vaccines?
  • Does your child have any allergies?*

  • Authorization of Care of Minor

    The statements made on this form are accurate to the best of my knowledge. I hereby authorize this clinic and its doctor(s) to administer care as they so deem necessary to my son/daughter/ward.

  • DATE:*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: