Pediatric Intake Form
Date of Birth:
Social Security #:
Number of Siblings:
Street Address Line 2
District of Columbia
Please enter a valid phone number.
Please enter a valid phone number.
(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)
Purpose of Visit:
Please state the reasons for your visit to our office today
Is there a history of any problems that the doctor should know about? Choose all that apply
Arm or shoulder condition
Inability to thrive
Ear infection (chronic)
How was the baby delivered?
Were forceps used in the delivery process?
Was vacuum extraction used in the delivery process?
How many hours was the labor?
How long was the pushing (in minutes)?
Was this a single or multiple birth?
What was the birth weight (pounds)?
What was the birth weight (ounces)?
What was the length of the child at birth (inches)?
What was the total APGAR score (5 minutes after birth, 10 is perfect)?
At how many weeks was the child born (gestational age in weeks)?
Were there any significant falls or traumas to the mother during the pregnancy?
List any evidence of birth trauma:
Cord around neck
Stuck in birth canal
Fast or excessively slow birth
Does the child have any history of serious falls or injuries, including fractures, concussions, hospitalizations, etc.?
Does the child wear a backpack?
Does child participate in sports or exercise activities?
Does child engage in any hobbies or activities which require prolonged, awkward or repetitive postures (violin, gymnastics, ballet, etc.)?
As an infant, was the child breastfed?
Was formula introduced?
Was cow's milk introduced?
Have solid foods been introduced?
Does the child have any food, liquid or juice intolerances or allergies?
During the pregnancy, did the mother smoke?
During the pregnancy, did the mother drink alcohol?
During the pregnancy, did the mother use recreational drugs?
Did the mother suffer any illnesses during the pregnancy?
Were any nutritional supplements prescribed or taken during the pregnancy?
Were ultrasound(s) performed during the pregnancy?
Were any invasive procedures performed during the pregnancy (Amniocentesis, Cerclage, etc.)?
Are there any pets in the child's home?
Are there any smokers in the child's home or environment?
Has the child had any adverse reactions to vaccinations or medicines?
Is there any history of antibiotics given to the child?
Have there been any difficulties with child-parent bonding?
Does the child have any behavioral problems?
Have any of the following behaviors occurred? Check all that apply
Stutter or stammer
Failure to maintain eye contact
On average, how many hours per week of television does the child watch?
Do you feel the child’s social and emotional development is normal for their age?
Was there any delay in terms of the child's achievement of developmental goals? Choose all that apply
None, all developmental goals were met on schedule
Delayed response to sound
Delayed normal appearance of teeth
Delayed ability to follow an object
Delayed ability to crawl
Delayed ability to hold head up
Delayed ability to walk
Delayed ability to vocalize
Delayed ability to sit alone
Which vaccines has the child had to date? Choose all that apply. If all vaccination are up to date, select "Received all childhood vaccinations."
Received all childhood vaccinations on schedule
Was not vaccinated
DTP (Diphteria, Tetanus and Pertussis)
Haemophilus Influenza type B (HbCV)
Hepatitis B (HBV)
Polio (OPV, IPV)
Human Papillomavirus (HPV, Gardasil)
I certify that I'm the patient or legal guardian of the patient listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my or the patient's condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me or the patient. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me or the patient will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. I understand and I am informed that in the practice of chiropractic there are some risks to treatment. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts known, is in my or the patient's best interest. I have read, and or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my or the patient's present condition and for any future condition(s) for which I or the patient seek treatment.
Should be Empty: