infinitelifeoc.com-Infinite Life Pediatric

Child’s Name

First Name Last Name

Birth Date

Age

Gender

Height

Weight

Parent’s/Guardian's Name

First Name Last Name

Parent’s Cell Phone

Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent’s Email

example@example.com

May we leave a message?

Yes No

Parent’s Work Phone

Area Code Phone Number

May we leave a message?

Yes No

Siblings and ages

How did you hear about us?

Has Yes your child ever been under Chiropractic Care?

Yes No

Emergency Contact

Name

First Name Last Name

Relationship to child

Phone Number

Area Code Phone Number

Alternative phone number

Area Code Phone Number

Family Doctor

Name

First Name Last Name

Professional Designation

Clinic Name

Date of last visit

Reason of last visit

May we communicate with your family doctor regarding your child’s care if necessary?

Yes No

Why have you decided to have your child evaluated by a Chiropractor?

He/She is continuing care from another chiropractor. I recently had my spine checked and understand the value in getting my child checked. I have concerns about his/her health and I’m looking for answers. He/She has a specific condition and I’ve learned that chiropractic may be able to help. I want to improve my child’s immune function.

Other Health Care Professionals

(Medical Specialist, Naturopathic Doctor, Homeopath, Physiotherapist, OT, Massage Therapist, etc)

Name

First Name Last Name

Professional Designation

Clinic Name

Date of last visit:

Reason of last visit

Name

First Name Last Name

Professional Designation

Clinic Name

Date of last visit

Reason of last visit

What signals has your child’s body been communicating?

	CURRENT	PREVIOUS
Asthma
Respiratory Infections
Sinus Problems
Ear Infections
Tonsillitis
Strep Throat
Frequent sickness
Recurrent Fevers
Eczema
Rashes
Allergies
Food Sensitivities
Digestive Problems
Frequent Diarrhea
Constipation
Flatulence
Headaches/Migraines
Neck Pain
Back Pain
Growing Pains

	CURRENT	PREVIOUS
Torticollis/Head Tilt
Trouble feeding on one side
Scoliosis
Red, Swollen, Painful Joints
Colic
Frequent Crying
Failure to Thrive
Slow or Absent Reflexes
Asymmetrical Crawling/Gait
Weight Challenges
Bed Wetting
Sleep Problems
Concentration Problems
Tie Toe Walking
Sensory Processing Issues
Seizures
Tremors/ Ticks
ADD/ADHD
Autism

Do you have a specific concern that brings you in?

No, I would like my child’s nervous system assessed to achieve optimal health & functioning. Yes

If yes, Describe

If yes, please answer the following questions:

Does your child appear to be in pain or discomfort?

When did it start?

Is it getting better, worse, or staying the same?

Suddenly or gradually?

Have you seen other health professionals regarding this complaint?

Yes No

If Yes, Whom?

What treatment did they use?

Has your child taken any medication for this complaint?

Yes No

If Yes, Please Describe:

Has your child ever experienced this complaint before?

Yes No

If Yes, Please Describe:

Has your child had x-rays in relation to the current complaint?

Yes No

If Yes, Please Describe:

Birth Experience

Location of Birth

Home Hospital Birthing Center

Medications during labor/delivery (including IV antibiotics)

Yes No

If Yes, Please Describe:

Was Pitocin used to induce / speed up labor?

Yes No

Was your child at any time during pregnancy in a constrained position?

Yes No Unsure

If yes, please describe

Breech Transverse Face / Brow presentation

Was your delivery vaginal or C-section?

Vaginal C-Section

Planned or emergency?

If it was vaginal, was the baby presented

Head Face Breech

Were any of the following interventions used?

Forceps Vacuum Extraction

Were there any complications during delivery?

Yes No

If yes, please specify

Was the baby born with any purple markings / bruising on their face or head?

Yes No

If Yes:

Any concerns about misshapen head at birth?

Yes No

Post Natal & Infant History

How many weeks gestation was the baby at birth?

Weight

Length

Was the baby ever admitted to the NICU?

Yes No

If yes, for how long and why?

Were there any medications given to the child at birth?

Yes No Unsure

If yes, what medication and why?

Was your child exclusively breastfed?

Yes No

How many months

Was your child breastfed + formula fed?

Yes No

How many months

Did your child show any sensitivities to formula (reflux, eczema, arching back)?

Yes No

Has your child been vaccinated?

Yes No

If yes

Full Partial Delayed

Did your child have any reactions to vaccines

Yes No

If yes, mention details

Physical Traumas

	Yes	No
Has your child ever fallen from any high places?
Has your child ever been involved in a motor vehicle accident?
Has your child broken any bones?
Has your child had any previous hospitalizations?
Has your child had any previous surgeries?

Does your child use a tablet, computer, or video game?

Never Rarely Daily Several hours/day

Does your child watch TV?

Never Rarely Daily Several hours/day

Does your child exercise?

No Daily Weekly

Does your child play contact sports?

No Daily Weekly

Goals & Consent

Do you feel your child is developmentally appropriate for their age?

	Yes	No	Explain
Intellectually
Emotionally
Physically

Whatis your primary goal for your child in this office?

Our goals are to provide a detailed assessment of your child’s current status and provide to you the resources for a highly engaged and healthy child whose body is functioning at its absolute peak potential while they grow. Essential to this healthy growth is a nervous system functioning free from interference called subluxations. You’ve taken an important step for your child’s future through a chiropractic evaluation!

PEDIATRIC HEALTH HISTORY