Pediatric Health History

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Before we begin, we want to simply say that it's an honor to serve you and/or your family. We are stoked to take you through our process. Are you ready?* This field is required.
YESNO
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What is Your Child's Name* This field is required.Full legal spelling of your first and last name
First Name
Last Name
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Preferred name/nickname for child
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Date of Birth of Child* This field is required.
Your Birth Date
Month
Day
Year
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Social Security Number of Child* This field is required.*We are required to collect this by the State of California
Ex: 123-45-6789
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Does your child have siblings?* This field is required.
YESNO
8
Siblings* This field is required.Please list the names and ages of your siblings
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Parent Information * This field is required.
Name
Phone number
Employer
Email
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Whom can we thank for referring you to our office?* This field is required.
11
What size shirt does your child wear?* This field is required.Click the one that best applies at current age.
Onesie 6-12 mos (or smaller)
Youth X-Small
12-18 mos
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
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Has your child ever received chiropractic care?* This field is required.
YESNO
13
Name of D.C. * This field is required.Please list the name of the chiropractor your child received care with
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Previous Chiropractic Care * This field is required.
Reason for care
How long?
Date of last visit
How did they respond with care?
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Have you ever consulted, or do you regularly consult with, any of the following providers for your child?* This field is required.
Naturopath
Acupuncturist
Homeopath
Energy Healer
Psychotherapist
Massage Therapist
Other
None
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Pediatrician * This field is required.
Pediatrician's name
Date of last visit
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Does your child have a present Complaint or Concern?* This field is required.
YESNO
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What is the reason for the visit today?* This field is required.
19
When did this condition begin?* This field is required.
20
Is the condition:* This field is required.
Getting Worse
Improving
Constant
Intermittent
Unsure
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What makes the condition better?* This field is required.
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What makes the condition worse?* This field is required.
23
Has your child ever had a similar condition before?* This field is required.
YESNO
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Is the condition interfering with:* This field is required.
School
Sleep
Playing
Walking
Eating
Attention/Focus
Exercise/Sports
Communication
None
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Please explain how this condition interferes with daily life:* This field is required.
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Has your child been seen for this condition?* This field is required.
YESNO
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Please explain how your child has been seen for this condition.* This field is required.
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Please check if your child has experienced any of the following conditions:* This field is required.
ADHD
Asthma
Allergies
Auto Accident
Bed Wetting
Behavioral Problems
Colic
Constipation
Dental Problems
Digestive Problems
Depression
Ear Infections
Fainting
Fatigue/Low Energy
Frequent Colds/Flus
Growing Pains
Irritability
Loss of Balance
Poor Coordination
Poor Posture
Recurring Fever
Scoliosis
Seizures
Sleeping Problems
Sensitivity to Light
Vision Changes
Walking Trouble
Other
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Pregnancy & Birth* This field is required.Please list the name of your Obstetrician or Midwife
30
For the following questions, did you/the mother, experience any significant illnesses, difficulties, or trauma during pregnancy?* This field is required.
YESNO
31
Please explain illness/difficulty/trauma:* This field is required.
32
Did you take any drugs/medications/supplements?* This field is required.
YESNO
33
Please explain drugs/medications/supplements you took during pregnancy:* This field is required.
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Did you smoke or consume alcohol during pregnancy?* This field is required.
YESNO
35
Any exposure to ultrasound during pregnancy?* This field is required.
YESNO
36
How many ultrasounds and what was the medical reason?* This field is required.
37
Was the delivery premature? * This field is required.
YESNO
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Premature Birth * This field is required.
Number of weeks your child was born at
Child's birth weight
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Approximately how long did labor last?* This field is required.Number of hours
40
What was the birth process like?* This field is required.
Vaginal
Medications
Forceps
Caesarian
Breach
Episiotomy
Epidural
Induced
Home or Water Birth
Vacuum Extraction
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Please list reasons for any interventions/complications:* This field is required.
42
Does your child have any genetic disorder or disabilities? * This field is required.
YESNO
43
Please explain genetic disorder or disability.* This field is required.
44
Was your child alert and responsive within 12 hours of delivery?* This field is required.
YESNO
45
Please explain why your child was not alert/responsive within 12 hours of delivery:* This field is required.
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Growth & Development * This field is required.
Child's birth weight
Child's birth length
Current weight
Current height
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APGAR* This field is required.
APGAR score at birth
APGAR score after 5 minutes
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At what age did your child:* This field is required.
Respond to sound
Follow an object
Hold head up
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At what age did your child:* This field is required.
Vocalize
Sit alone
Teethe
50
At what age did your child:* This field is required.
Crawl
Stand alone
Walk
51
Is/was your child breastfed?* This field is required.
YESNO
52
How long was your child breastfed?* This field is required.
53
Any difficulty with breastfeeding?* This field is required.
YESNO
54
Please explain difficulty with breastfeeding:* This field is required.
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Ok
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Early Food Intake * This field is required.
If formula was introduced, at what age AND what type?
Introduction of cow's milk at age
Began solids at age
56
Any food allergies/intolerances?* This field is required.
YESNO
57
Please list food allergies or intolerances:* This field is required.
58
Any difficulty with bonding?* This field is required.
YESNO
59
Please explain difficulty with bonding:* This field is required.
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Small
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Ok
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Any behavioral problems?* This field is required.
YESNO
61
Please explain behavioral problem:* This field is required.
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Small
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Ok
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Any night terrors, sleep walking or difficulty sleeping?* This field is required.
YESNO
63
Please explain night terror, sleep walking, or difficulty sleeping: * This field is required.
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Ok
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Is your child taking any non-prescription or prescription drugs or medications?* This field is required.
YESNO
65
Please list any non-prescription or prescription or medication your child is taking: * This field is required.
66
Has your child had surgery or been hospitalized? * This field is required.
YESNO
67
Please explain why and when your child had surgery/hospitalization:* This field is required.
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68
What side effects has your child experienced form the drugs or surgery?* This field is required.
69
Have you chosen to vaccinate your child?* This field is required.
YESNO
70
Please check all vaccinations your child has received* This field is required.
Hepatitis
DPT
MMR
Chicken Pox
Flu
Other
71
Please explain any and all reactions to vaccine(s)* This field is required.
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Does your child eat well?* This field is required.
YESNO
73
Does your child have regular bowel/bladder movements?* This field is required.
YESNO
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According to the National Safety Council, approximately 50% of children fall head first from a high place during their first years of life (i.e. bed, changing table, down stairs, etc.). Was this the case for your child? * This field is required.
YESNO
75
Has your child ever been involved in a car accident? * This field is required.
YESNO
76
Please explain car accident:* This field is required.
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Small
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Ok
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Please list any major injuries, accidents, falls and/or fractures your child has had in his/her lifetime, including this year:* This field is required.
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78
Please indicate if your child has ever or currently experiences any of the emotional stresses below: * This field is required.
Academic pressure
Loss of a loved one
Bullying
Relocation
Lifestyle change
Parents' divorce
Loss of a pet
New sibling
None
79
Does your child have difficulty interacting with schoolmates or friends?* This field is required.
YESNO
80
At what age did your child begin daycare? If not applicable, mark N/A:* This field is required.
81
Average number of hours of TV/computer per week?* This field is required.
82
Are there any other health concerns or anything else you'd like us to know about your child?* This field is required.
YESNO
83
Please explain:* This field is required.
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I would like my child to experience the following benefits from Chiropractic care (check all that apply): * This field is required.
Feel better quickly
Correct the cause of a problem as well as relief
Prevent future problems
Live a healthier lifestyle
Healthier spine and nervous system
Optimal health on all levels
85
Signature: Terms of Acceptance* This field is required.When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our only practice objective is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.
Clear
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Signature: Consent to Care* This field is required.I do hereby authorize the doctor of Nexus Family Chiropractic to administer chiropractic care that is necessary for my particular case. This may include consultation, examination, adjustments or any other procedure which is advisable and necessary for my health care. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not. I also clearly understand that if I do not follow the doctors specific recommendations at Nexus Family Chiropractic that I will not receive the full benefit from the services, and that if I terminate my care prematurely that all fees incurred will be due and payable at that time. I understand that payment for care is out-of-pocket and paid before or directly after services are rendered. If I wish to obtain reimbursement from my health insurance company, Nexus Family Chiropractic will supply the proper documentation necessary to receive reimbursement for services. Nexus Family Chiropractic is not liable for any lack of reimbursement from my health insurance company. I have read, understand, and hereby request chiropractic care based on the terms of acceptance and the consent to care.
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Signature: Healthcare Authorization* This field is required.The following authorizes Nexus Family Chiropractic to use and/or disclose protected health care information in accordance with the following specific authorizations: I give permission to Nexus Family Chiropractic to use my name, address, phone numbers, and clinical records to contact me with birthday cards, holiday related cards, health related-emails and information about treatment alternatives or other health related information, as well as my advertisements, newsletters, or patient of the week/month postings. I give permission to Nexus Family Chiropractic to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protective health care information during my treatment. Should I need to speak with a doctor in private, the doctor will provide a private room for these conversations. By signing the following you are giving Nexus Family Chiropractic permission to use and disclose your protected health information in accordance with the directives listed above. ACKNOWLEDGEMENT OF RECEIPT & NOTICE OF PRIVACY PRACTICES I understand and have been provided with a notice of information practices that provides me a more complete description of information uses and disclosures, I understand that I have the following rights and privileges: * The right to review the notice prior to signing this consent * The right to object to the use of my health care information for directory purpose * The right to request restrictions as to how my health care information may be used or disclosed in this office to carry out treatment, payment, or health care operations.
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