Pediatric Intake*Ages 12 and under Child's Name * First Name Last Name Parent/Guardian Name * First Name Last Name Date of Birth * MM DD YYYY Current Height * Current Weight * Phone * (###) ### #### What cell service provider do you use? * Email: * How did you hear about us? * Has your child been adjusted by a chiropractor before? * Yes No If yes, reason for those visits and date of last visit: Is your child currently receiving care from other health professionals? Yes No If yes, list name and specialty: Describe the health concern that prompted this visit: * When did this concern begin? * How did this concern begin? * Has this condition: * Worsened Stayed the same Been intermittent Does this interfere with: School Sleep Daily Routine Family What makes this condition worse? * What makes this condition better? * Please list any medications your child is currently taking. Including dosage and frequency (including OTC): Child's birth was at: * Home Birthing Center Hospital Unknown Child's birth was: * Natural vaginal with no medications Vaginal with interventions C-Section Birth history unknown Was your child at any time during your pregnancy in a constrained position? * Yes No Unsure If yes, please describe: Medications during pregnancy? * Yes No If yes, which ones and how often? (include OTC) Exposure to drugs, alcohol, cigarettes, or secondhand smoke during pregnancy? Yes No Birth Weight * Please list all hospitalizations and surgical history (include year): * Please list any major injuries, accidents, falls and/or fractures your child has sustained in his/her lifetime: * Please check any symptoms your child is CURRENTLY experiencing or has experienced in the PAST: ADD / ADHD Asthma Autism Back Pain Bed Wetting Colic Constipation Digestive Problems Ear Infections Eczema Failure to Thrive/Slow Weight Gain Flatulence Food Sensitivities Frequent Colds/Croup Frequent Crying Spells Frequent Diarrhea Growing Pains Headaches/Migraines Neck Pain Night Terrors Rashes Recurrent Fevers Scoliosis Seizures Sensory Processing Issues Sinus Problems Sleep Problems Strep Throat Tip Toe Walking Tonsillitis Torticollis/Head Tild Trouble Nursing Tremors/Shaking Weight Challenges What is your primary goal at our clinic? * We can’t wait to meet you!
