brookevillechiropractic.com - CHILDREN’S CHIROPRACTIC HISTORY

CHILDREN’S CHIROPRACTIC HISTORY
Patient’s Name:

First NameLast Name
Today’s Date:

MonthDayYear
Date
Child’s DOB:

MonthDayYear
Date
Mom’s Name:
Dad’s Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Insurance Co:
Insured’s Name:
Insured’s Date of Birth:

MonthDayYear
Date
Insured’s SS#
Who Referred you:
Sex:

MaleFemale
Number of Siblings:
POSTNATAL AND INFANT HISTORY
Has your child ever suffered from?

AllergiesDigestive ProblemsEye ProblemsHyperactivityAsthmaEar infections/fluidRespiratory InfectionsScoliosisBedwettingPoor immune systemHeadachesDizzinessColicHearing ProblemsTonsillitisGrowing Pains
Purpose of visit:
Who is your child’s pediatrician?
Pediatrician phone:
Please enter a valid phone number.
Date of last visit:

MonthDayYear
Date
Are you satisfied with the care you receive there?

YesNo
Birth Height
Birth Weight
Current Height
Current Weight
Apgar scores:
Was there a presence of

Jaundice (Yellow)Cyanosis (blue)
Was baby ever in NICU?

YesNo
If yes, why?
Congenital anomalies/defects?
Was any medication given to baby at birth?

YesNo
If yes, why?
Is your child taking any medication now?
Was your child

BreastfedFormula-fed
For how long?
Did your child show any sensitivities to formula? (Reflux, eczema, arching back, spit up)?

YesNo
What age did you introduce solid foods to your child _____months
First solid food:
Introduced to cow’s milk at what age?
Any known food allergies:
# of antibiotics prescribed:
During the past 6 months?
Reason:
Total during baby’s lifetime?
Reason:
PRENATAL HISTORY
Problems during pregnancy:
Medications during pregnancy:
OB/Gyn. Name:
OB/Gyn. Phone #:
Please enter a valid phone number.
BIRTH EXPERIENCE
Birth location:

HomeHospitalBirthing CenterOther
Birth attendants:

DoulaMidwifeGPOBOther
Mediations during labor / delivery (including IV antibiotics)?

YesNo
If yes, describe:
Was Pitocin used to induce/speed up labor?

YesNo
Problems during labor:
Was your delivery

VaginalC-Section?
If C-section, was it

PlannedEmergency
Why?
How long was your labor:
How long was pushing:
If it was vaginal, were any used during delivery?

ForcepsVacuum ExtractionOther
PHYSICAL TRAUMAS
Has your child ever fallen from a high place?

YesNo
Has your child ever been involved in a motor vehicle accident?

YesNo
Has your child ever been seen on an emergency basis?

YesNo
Has your child ever broken any bones?

YesNo
Has your child ever had any previous surgeries?

YesNo
DEVELOPMENTAL HISTORY
At what age was your child able to?
Respond to Sound
e.g. 2
Cross Crawl
e.g. 2
Respond to Visual Stimuli
e.g. 2
Stand Up
e.g. 2
Hold Head Up
e.g. 2
Walk alone
e.g. 2
Sit Up
e.g. 2
I hereby authorize this clinic and its Doctor(s) to administer care as they so deem necessary to My Son / Daughter / Ward.
Signed:

Clear
Date:

MonthDayYear
Date
Signature on file and authorization to release medical information:

I HEREBY AUTHORIZE PAYMENT OF INSURANCE BENEFITS DIRECTLY TO THE DOCTOR FOR SERVICES PROVIDED. I FURTHER AUTHORIZE THE DOCTOR TO RELEASE ANY INFORMATION REQUIRED TO PROCESS INSURANCE CLAIMS.
Signed:

Clear
Date:

MonthDayYear
Date
Should be Empty:

CHILDREN’S CHIROPRACTIC HISTORY

POSTNATAL AND INFANT HISTORY

PRENATAL HISTORY

BIRTH EXPERIENCE

PHYSICAL TRAUMAS

DEVELOPMENTAL HISTORY