brookvillechiropractic.com - CHILDREN’S CHIROPRACTIC HISTORY

CHILDREN’S CHIROPRACTIC HISTORY
Child's Name

First NameLast Name
Today’s Date:

MonthDayYear
Date
Email Address:
example@example.com
Mother’s Name:
Father’s Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Father’s Cell Phone:
Please enter a valid phone number.
Mother’s Cell Phone:
Please enter a valid phone number.
Insurance Co:
Insurance Address:
Insured’s Name:
Insured’s Date of Birth:

MonthDayYear
Date
Insured’s Employer:
Insured’s SS#
Child’s Birthdate:

MonthDayYear
Date
Age:
Birth Weight:
Current Weight:
Birth Length:
Current Length:
Purpose for contacting our office:
Who referred you to our office:
Prenatal History:
Problems during pregnancy:
Medications during pregnancy:
OB/Gyn. Name:
OB/Gyn. Phone #:
Please enter a valid phone number.
Labor/Birth History:
Problems During Labor/Delivery:
Type of Birth:

Vaginal:Forceps:Vacuum Extraction:Breech
Cesarean:

Emergency:Planned:Reason:Epidural:
Medications during labor:
Place of Birth:

HomeBirthing Center:Hospital:
Apgar Scores:
Was there presence of

Jaundice (Yellow)Cyanosis (Blue)
Congenital Anomalies/Defects:
Infant Feeding History:
Breastfed:
How long?
Formula:
How long?
Introduced to solids at what age:
First solid food(s):
Introduced to cow’s milk at what age:
Any known food allergies?
Medical History:
Pediatrician’s Name:
Pediatrician’s Phone #:
Please enter a valid phone number.
Date of last visit:

MonthDayYear
Date
Are you satisfied with care there?
No. of antibiotics prescribed:
During the past 6 months?
Reason:
Total during his/her lifetime?
Reasons:
Number & explanation of other prescriptions:
Has your child had any surgeries or illnesses?
Vaccination History:
Has he/she had any known side effects or allergic reactions from their vaccines?
Does your child have learning disabilities/ autism/ or ADHD?
Has your child been treated on an emergency basis?

YesNo
Describe:
Has your child ever been involved in a car accident?

YesNo
If yes, when?
According to the National Safety Council, approximately 50% of children fall head first from a high place their first year of life! Did this happen to your child

YesNo
If yes, how old was he/she?
Where was the fall(s) from?
Developmental History:
During the following times, a child’s spine is most vulnerable and should routinely be checked by a
Doctor of Chiropractic for Prevention and Early Detection of the Subluxation Complex.
At what Age was your child able to:
Respond to Sound
Respond to Sound
Respond to Visual Stimuli
Hold Head Up
Sit Up
Cross Crawl
Stand Up
HAS YOUR CHILD EVER SUFFERED FROM:

AllergiesDigestive ProblemsEye ProblemsHyperactivityAsthmaEar Infections/fluidRespiratory InfectionsScoliosisBedwettingPoor Immune responseHeadachesDizzinessColicHearing ProblemsTonsilitisGrowing Pain
I hereby authorize this clinic and its Doctor(s) to administer care as they so deem necessary to
My Son / Daughter / Ward.
Signed:

Clear
Date:

MonthDayYear
Date
Signature on file and authorization to release medical information:
I HEREBY AUTHORIZE PAYMENT OF INSURANCE BENEFITS DIRECTLY TO THE DOCTOR FOR
SERVICES PROVIDED. I FURTHER AUTHORIZE THE DOCTOR TO RELEASE ANY INFORMATION
REQUIRED TO PROCESS INSURANCE CLAIMS.
Signed:

Clear
Date:

MonthDayYear
Date
Should be Empty:

CHILDREN’S CHIROPRACTIC HISTORY

Prenatal History:

Labor/Birth History:

Infant Feeding History:

Medical History:

Developmental History: