Pediatric Paperwork

List any traumas, injuries, or surgeries the patient has had and when:

Does the patient have any allergies? If yes, please list them

Please list any supplements and/or medications the patient has taken recently:

What are your current health and well being goals for the patient?

Immunization Status

Not Vaccinated Fully Vaccinated according to the CDC schedule Modified Vaccination Schedule

Have you noticed: (pick all that apply)

Child prefers one breast to the other Child spits up frequently during or after feeding Tongue or Lip Tie Child's head is misshapen None of the above

Please mark any that apply to the patient now or in the past

Does anyone in the patients IMMEDIATE family have a history of:

Heart Disease: If yes, who

Diabetes: If yes, who

High Blood Pressure: If yes, who

Stroke: If yes, who

Cancer: If yes, who

Other Relevant Family History:

Is there anything else you would like us to know?

Please sign below to indicate that you have read the above information and have filled out this form as accurately as possible.

Signature Clear

I have reviewed the HIPAA privacy practices for Frederick Chiropractic (above).

Parent or Guardian Signature Clear

Consent Form

I have reviewed the Consent Forms for Frederick Chiropractic (above)

Guardian Signature Clear

Name of Guardian :

Name of Patient:

Date

Please verify that you are human *

Frederick Chiropractic Pediatric Confidential Patient Health History