Frederick Chiropractic Pediatric Confidential Patient Health History
New Patient Paperwork for patients 12 and under
Today's Date:
/
Month
/
Day
Year
PATIENT INFORMATION
Name: (Last, First, MI)
Preferred Name:
Date of Birth
January
February
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December
Month
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1927
1926
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Year
Preferred Language:
Height:
Weight:
Gender:
Race:
Asian
Black or African American
American Indian or Alaskan Native
White (caucasian)
Hawaiian or Pacific Islander
Other
Decline
CMS requires providers to report both race and ethnicity
Ethnicity
NOT Hispanic or Latino
Hispanic or Latino
Other
Decline to Answer
Name of current pediatrician
Phone number of current pediatrician
Guardian Information
Name of Guardian
First Name
Last Name
Relation to the Patient
Home Phone:
Mobile:
Work:
Social Security number:
Email:
example@example.com
Occupation:
Marital Status:
Married
Single
Other
Employer:
Address Information:
Address
Street Address Line 2
City
State
Zip
Does the patient also live at this address? If no, please fill in address of where the patient resides.
Childrens Names and Ages:
Referred by:
Family
Friend
CoWorker
Doctor
Other
Referred by (name):
EMERGENCY CONTACT INFORMATION
Full Name and Phone Number:
Relationship:
Child
Parent
Spouse
Other
Please list the name, relation, and phone number of anyone else permitted to bring the patient to future appointments:
Financial Information
Name and Date of Birth of Primary Insurance Holder
Patients Relation to Insured
Self
Spouse
Parent
Child
Please select how you would like for your visits to be billed
Self Pay (Cash)
Insurance
Personal Injury/Auto
If possible, please attach a picture of the BACK of your insurance card
Browse Files
Cancel
of
If possible, please attach a picture of the FRONT of your insurance card
Browse Files
Cancel
of
Name of Primary Insurance:
Name of Secondary Insurance:
Back
Next
Patient Health History
Please Answer ALL Questions
Has the patient previously been seen by a chiropractor?
If yes, where?
How did the patient respond?
Why are you seeking Chiropractic Care? If consultation is for wellness and your child does not have a "complaint" please proceed to the PATIENT HISTORY section.
When Did It Start (date):
What Event Caused It:
How is this affecting your child's life? (Ex: Sleep is interrupted)
Is the complaint present:
All the time
After Eating
At Night
What makes it better?
Ice
Heat
Rest
Movement
Stretching
Over the counter medication
Prescription medication
Chiropractic
What makes it worse?
Sit
Stand
Walk
Lying
Sleep
Movement
Who else have you seen for this?
No One
Doctor of Chiropractic
Medical Doctor
Physical Therapist
Masseuse
Emergency Room
If yes, what treatment was administered?
Draw Areas of Complaints
Any Other Complaints or Concerns?:
Back
Next
Patient History
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
Asthma
Frequently Sick
Ear Infection
Colic
Insomnia
Depression
Cancer
Anxiety
Jaundice
Constipation
Joint Pain
Dizziness
Headaches
Hypractivity
Surgery
Mood Swings
Backache
Frequent Stomach Aches
Diarrhea
Difficulty Concentrating
Bed Wetting
Heart Palpitations
Bruises Easily
Seizures
Skin Irritability/ Itchiness
Falls Often
Autoimmune Disorders
Been Hospitalized
Hormone Imbalance
Family/Home Stress
Autistic Spectrum
Down Syndrome
Unexpected Weight Loss/ Gain
Foggy Thinking
Sugar Cravings
Ringing In Ears
Blind
Deaf
Use of Forceps or Vacuum during birth
Premature Delivery
Chemically Induced Labor
Medicated Birth
Eating or Nursing Problems
Illness During Pregnancy
Scoliosis
Frequent Fevers
Involved in a Car Accident
Learning Difficulty
Repeated Colds/Runny Nose
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
-
Month
-
Day
Year
All Set! Select "Submit" below, and we will receive your information. We look forward to meeting you.
-Frederick Chiropractic Team
Submit
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