Radiant Life Chiropractic - Pediatric New Patient Form

Pediatric New Patient Form

Please fill out thoroughly, complete form, and submit to Radiant Life Chiropractic for review at least 24 hrs prior to the day your initial exam is scheduled. Thank you for helping us serve your family better!
Patient Information
Name

First NameLast Name
Parent's Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Birthday

MonthDayYear
Date
Age
Have you or your child ever had chiropractic care before?
If yes, please tell us the doctor's name.
Were you pleased with your care?
If yes, please name them and their specialty
How did you find out about our office?
Who is your family’s primary care physician?
Is your child receiving care from other health professionals?
Please list any allergies your child has
Current Health
What health condition brings your child to our office?
Is this condition
When did the symptoms first begin?
How did the problem start?
What makes the problem better?
What makes the problem worse?
Please explain
Has your child been treated for this problem before?
Please explain
Does your child eat well?
Does your child have regular bowel/bladder movements?
Has your child ever been checked for vertebral subluxations?
Health History
Child’s birth was
My obstetrician/midwife/family physician was
Please Select
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 and Development
Was your child alert and responsive within 12 hours of delivery?
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)
Please list any major injuries, accidents, falls and/or fractures your child has sustained in his/her lifetime, including the year
Is/was your child breastfed?
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?
Did mother drink alcohol during pregnancy?
Any illness of mother during pregnancy?
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?
Any pets at home?
If so, how many and what was the medical reason?
Any smokers at home?
Has child received any vaccinations?
If yes, which ones and list any reactions
Has child received any antibiotics?
If yes, how many times and list reason
Any difficulty with breastfeeding?
If yes, please explain
Any difficulty with bonding?
If yes, please explain
Any behavioral problems?
If yes, please explain
Any night terrors, sleepwalking or difficulty sleeping?
If yes, please explain
If no, please explain
Does your child seem normal for their age?
Age child began daycare
Average number of hours of TV per week
Family History Review
Check those involving immediate family and add identification: M
If yes, please mention type
Depression
Neck/Back Problems
Heart Disease
Liver Disease
High Blood Pressure
High Cholesterol
Lung Problems
Scoliosis
Osteoporosis
Rheumatoid Arthritis
Seizures
Osteoarthritis
Chiropractic Knowledge
What would you like to gain from chiropractic care?
Do you know what a subluxation is?
Do any of your friends or relatives see a chiropractor?
If yes, do they use chiropractic for
Are you seeking chiropractic for
Are there other health concerns or anything else you’d like us to know about your child?
Detailed Review of Systems
Cardiovascular
Past
Present
Genitourinary
Past
Present
Hematologic/Lymphatic
Type a question
Past
Present
Respiratory
Past
Present
Ear/Nose/Throat
Past
Present
Eyes
Past
Present
Allergic/Immunologic
Past
Present
Gastrointestinal
Past
Present
Musculoskeletal
Past
Present
Neurological
Past
Present
Endocrine
Past
Present
Constitutional
Past
Present
Psychiatric
Past
Present
Should be Empty: