Pediatric Vital Information

Pediatric Vital Information

Pediatric Vital Information

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Pediatric Vital Information

Connect Chiropractic Studio
Pediatric Vital Information
Your genes are not your destiny.

Your environment determines what genes are turned on and how they express.

Your biography becomes your biology.
Basic Information
Child's Name

First Name Last Name
Gender
DOB

- Month - Day Year
Age
Parent/Guardian's Names, Phone Number & Email

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Sibling's Name(s)

History
Was this birth planned?
Were fertility measures taken? Please explain.
Did mom use any of the following during pregnancy?

Tobacco Alcohol Medications Drugs
^ Please Explain:
Did any occur during pregnancy?

Falls or injuries Abuse (physical, sexual, emotional) Complications
^ Please Explain:
Please describe your stress level during pregnancy.

Child's Birth History
Third Trimester Presentation:

Vertex Breech Transverse Face or Brow
Type of Birth:

Vaginal Cesarean ER Cesarean Planned
Birth Assistance or Interventions:

Forceps Suction or Vacuum Pitocin Epidural Ruptured Membrane Episiotomy Other Medication
Complications during birth:
APGAR at Birth
APGAR after 5 min
Birth Weight
Birth Length
Please explain anything marked above in this section or any other details:

Child's History
Breast Fed
^ How long breast fed?
Difficulties nursing:
Formula Fed
^ How long formula fed?
Reason formula fed?
Age when solids were introduced.
Texture Sensitivities
Food Sensitivities:
Allergies

Food Medicine Other
Please explain anything marked above in this section.

Child's History
Mark all that apply

Crawled before walking Shoulder or elbow dislocations Played in a hanging/bouncy swing
Sit independently Crawl forward with opposite hand and knee Stand independently Walk independently Jump Skip Pinch Read Write
Mark all that apply for current bowl/bladder trends

Diapers all day and night Diaper/pull up at night only Enuresis (bed wetting) Teaching elimination communications Bowel movement at least once daily
Difficulties bonding:
Behavioral problems:
Allergies
Vaccine history

Full CDC Selective Schedule Delayed, Full CDC None
Medications
Supplements
Child's Diet/Mom's if breastfeeding

Child's History
Mark all secondary conditions that your child CURRENTLY has:

ADD/ADHD Asthma Asthma/respiratory disease Autism/Asberger's Syndrome Auto accident Bed-wetting Bowel/Bladder changer Broken bone Chicken Pox Cancer Colic Concussion/Head injury Dental/Jaw issues Depression Diabetes Digestive problems Dizziness/Vertigo Ear infection Eye/Vision issues Frequent colds/flu Headaches Growing pains Neck/Back pain Reflux Scoliosis Seizures Sensory integration issues Skin condition Sinus Surgery Stroke Thyroid disorder Urinary tract Weight changes Other
Mark all secondary conditions that your child has had in the PAST:

ADD/ADHD Asthma Asthma/respiratory disease Autism/Asberger's Syndrome Auto accident Bed-wetting Bowel/Bladder changer Broken bone Chicken Pox Cancer Colic Concussion/Head injury Dental/Jaw issues Depression Diabetes Digestive problems Dizziness/Vertigo Ear infection Eye/Vision issues Frequent colds/flu Headaches Growing pains Neck/Back pain Reflux Scoliosis Seizures Sensory integration issues Skin condition Sinus Surgery Stroke Thyroid disorder Urinary tract Weight changes Other
^Explain anything marked above:

Current Health Concerns
What is the reason for your appointment?
Do you have any ideas why this is occurring?
Is there any other issue/symptom that you believe is related to this?
When did this begin?
Is it related to:
Have you done anything or gotten any advice or treatment for this issue outside of this office? (If yes, from who and what was the result?)
What activities aggravate the condition?
What activities alleviate the condition?
Is the condition worse during certain times of the day? (If yes, when?)

Childs History
Have you been to a chiropractor?
Has your child been to a chiropractor?
Child's healthcare team: (Please include name, provider type, last visit, reason and result if applicable)
Is there anything else we should know about your child's body and nervous system?
Guardians Electronic Signature
Date

- Month - Day Year
Please make sure all the information is as thorough as possible and complete before you submit. If you have any questions please contact me at 470-344-4039 or email info@connectchiropracticstudio.com.
Dr. Notes Area
Doctor Electronic Signature
Date

- Month - Day Year
Should be Empty:

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