Pediatric New Patient Form
Please fill out thoroughly, complete form, and submit to Radiant Life Chiropractic for review at least 24 hrs prior to the day your initial exam is scheduled. Thank you for helping us serve your family better!
Patient Information
Name
*
First Name
Last Name
Parent's Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Birthday
*
-
Month
-
Day
Year
Date
Age
*
Have you or your child ever had chiropractic care before?
*
Yes
No
If yes, please tell us the doctor's name.
Were you pleased with your care?
Yes
No
If yes, please name them and their specialty
How did you find out about our office?
Who is your family’s primary care physician?
Is your child receiving care from other health professionals?
Yes
No
Please list any allergies your child has
*
Current Health
What health condition brings your child to our office?
Is this condition
Getting better
Staying the same
Getting worse
When did the symptoms first begin?
How did the problem start?
Gradually
Suddenly
After an injury
What makes the problem better?
What makes the problem worse?
Please explain
Has your child been treated for this problem before?
Yes
No
Please explain
Does your child eat well?
Yes
No
Does your child have regular bowel/bladder movements?
Yes
No
Has your child ever been checked for vertebral subluxations?
Yes
No
I'm not sure
Health History
Child’s birth was
At Home
At Birthing Center
At Hospital
My obstetrician/midwife/family physician was
Please Select
Natural vaginal (no mediciations/interventions)
Vaginal with interventions
- Induction
- Pain medication
- Epidural
- Episiotomy
- Forceps
- Other
- C-section Scheduled
- C-section Emergency
Please list reasons for any interventions/complications
Child’s birth weight
Child’s birth height
Current weight
Current height
APGAR score at birth
APGAR score after 5 minutes
Growth and Development
Was your child alert and responsive within 12 hours of delivery?
Yes
No
If no, please explain
At what age did the child:
Respond to sound
Follow an object
Hold head up
Vocalize
Sit alone
Teethe
Crawl
Walk
Patient/Hospitialization/Surgical history (please list below all surgeries and hospitalizations, including the year)
Please list any major injuries, accidents, falls and/or fractures your child has sustained in his/her lifetime, including the year
Is/was your child breastfed?
Yes
No
If yes, how long?
Formula introduced at age
What type?
Introduction of cow’s milk at age
Began solid foods at age
Please list any foods/juice intolerance
Did mother smoke during pregnancy?
Yes
No
Did mother drink alcohol during pregnancy?
Yes
No
Any illness of mother during pregnancy?
Yes
No
If yes, please explain including treatment/medications/supplements
List any drugs/medications (including over the counter) taken during pregnancy
List any supplements taken during pregnancy
Any exposures to ultrasound?
Yes
No
Any pets at home?
Yes
No
If so, how many and what was the medical reason?
Any smokers at home?
Yes
No
Has child received any vaccinations?
Yes
No
If yes, which ones and list any reactions
Has child received any antibiotics?
Yes
No
If yes, how many times and list reason
Any difficulty with breastfeeding?
Yes
No
If yes, please explain
Any difficulty with bonding?
Yes
No
If yes, please explain
Any behavioral problems?
Yes
No
If yes, please explain
Any night terrors, sleepwalking or difficulty sleeping?
Yes
No
If yes, please explain
If no, please explain
Does your child seem normal for their age?
Yes
No
Age child began daycare
Average number of hours of TV per week
Family History Review
Check those involving immediate family and add identification: M
M
F
S
G
If yes, please mention type
Depression
M
F
S
G
Neck/Back Problems
M
F
S
G
Heart Disease
M
F
S
G
Liver Disease
M
F
S
G
High Blood Pressure
M
F
S
G
High Cholesterol
M
F
S
G
Lung Problems
M
F
S
G
Scoliosis
M
F
S
G
Osteoporosis
M
F
S
G
Rheumatoid Arthritis
M
F
S
G
Seizures
M
F
S
G
Osteoarthritis
M
F
S
G
Chiropractic Knowledge
What would you like to gain from chiropractic care?
Do you know what a subluxation is?
Yes
No
Kind of
Do any of your friends or relatives see a chiropractor?
Family
Friend
Nobody I know
If yes, do they use chiropractic for
Health maintenance/optimization
Health Problems
Both
Are you seeking chiropractic for
Health maintenance/optimization
Health Problems
Both
Are there other health concerns or anything else you’d like us to know about your child?
Detailed Review of Systems
Cardiovascular
Past
Poor Circulation
High Blood Pressure
Aortic Aneurysm
Heart Disease
Heart Attack
Chest Pain
High Cholesterol
Pacemaker
Jaw Pain
Irregular Heartbeat
Swelling of Legs
Stroke
Present
Poor Circulation
High Blood Pressure
Aortic Aneurysm
Heart Disease
Heart Attack
Chest Pain
High Cholesterol
Pacemaker
Jaw Pain
Irregular Heartbeat
Swelling of Legs
Stroke
Genitourinary
Past
Kidney Disease
Lower Side Pain
Burning Urination
Frequent Urination
Blood in Urine
Kidney Stone
Bed Wetting/Enuresis
Prostate Problems
Rectal Prolapse
Present
Kidney Disease
Lower Side Pain
Burning Urination
Frequent Urination
Blood in Urine
Kidney Stone
Bed Wetting/Enuresis
Prostate Problems
Rectal Prolapse
Hematologic/Lymphatic
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Past
Poor Circulation
High Blood Pressure
Aortic Aneurysm
Heart Disease
Heart Attack
Chest Pain
High Cholesterol
Pacemaker
Jaw Pain
Irregular Heartbeat
Swelling of Legs
Stroke
Present
Poor Circulation
High Blood Pressure
Aortic Aneurysm
Heart Disease
Heart Attack
Chest Pain
High Cholesterol
Pacemaker
Jaw Pain
Irregular Heartbeat
Swelling of Legs
Stroke
Respiratory
Past
Asthma
Shortness of Breath
Upper Resp. Infection
Cold/Flu
Pneumonia
Cough/Wheezing
Emphysema
RSV
Tuberculosis
Present
Asthma
Shortness of Breath
Upper Resp. Infection
Cold/Flu
Pneumonia
Cough/Wheezing
Emphysema
RSV
Tuberculosis
Ear/Nose/Throat
Past
Sinus Congestion
Sinus Infection
Nosebleed
Sore Throat
Difficulty Swallowing
Ear Ache
Ear Infections
Dizziness
Hearing Loss
Bleeding Gums
Present
Sinus Congestion
Sinus Infection
Nosebleed
Sore Throat
Difficulty Swallowing
Ear Ache
Ear Infections
Dizziness
Hearing Loss
Bleeding Gums
Eyes
Past
Glaucoma
Double Vision
Blurred Vision
Red, Itchy (Allergy)
Present
Glaucoma
Double Vision
Blurred Vision
Red, Itchy (Allergy)
Allergic/Immunologic
Past
Autoimmune Disorder
Chronic Allergies
Seasonal Allergies
Food Allergies
Environmental Allergies
Allergy Shots
Cortisone Use
HIV/AIDS
Hives
Weak Immune System
Present
Autoimmune Disorder
Chronic Allergies
Seasonal Allergies
Food Allergies
Environmental Allergies
Allergy Shots
Cortisone Use
HIV/AIDS
Hives
Weak Immune System
Gastrointestinal
Past
Pancreatitis
Acid Reflux
Bowel Problems
Constipation
Upset Stomach
Gas Pains
Ulcers
Gallbladder Problems
Liver Problems
Diarrhea
Nausea/Vomiting
Poor Appetite
Bloody Stools
Chrohn’s Disease
Hiatal Hernia
Present
Pancreatitis
Acid Reflux
Bowel Problems
Constipation
Upset Stomach
Gas Pains
Ulcers
Gallbladder Problems
Liver Problems
Diarrhea
Nausea/Vomiting
Poor Appetite
Bloody Stools
Chrohn’s Disease
Hiatal Hernia
Musculoskeletal
Past
Chronic Hip Dislocation
Torticollis
Poor Posture
Neck Pain
Back Pain
Arthritis
Rheumatoid Arthritis
Joint Stiffness
Muscle Weakness
Osteoporosis
Broken Bones
Joint Replacement
Gout
Present
Chronic Hip Dislocation
Torticollis
Poor Posture
Neck Pain
Back Pain
Arthritis
Rheumatoid Arthritis
Joint Stiffness
Muscle Weakness
Osteoporosis
Broken Bones
Joint Replacement
Gout
Neurological
Past
Tic Disorder
Seizures
Head Injury
Brain Aneursym
Numbness/Tingling
Pinched Nerves
Radiating Pain
Sciatica
Parkinsons Disease
Carpal Tunnel
Balance/Coordination
ADHD/ADD/Sensory Processing Disorder
Autism/Spectrum Disorder
Migraine Headaches
Bell’s Palsy
Poor Fine/Gross Motor Skills
Epilepsy
Inflammation
Trigeminal Neuralgia
Ear Ringing/Tinnitus
Auditory Processing
Toe Walking
Sinus Headache
Tension Headache
Vertigo/Dizziness
Sensory Integration
Present
Tic Disorder
Seizures
Head Injury
Brain Aneursym
Numbness/Tingling
Pinched Nerves
Radiating Pain
Sciatica
Parkinsons Disease
Carpal Tunnel
Balance/Coordination
ADHD/ADD/Sensory Processing Disorder
Autism/Spectrum Disorder
Migraine Headaches
Bell’s Palsy
Poor Fine/Gross Motor Skills
Epilepsy
Inflammation
Trigeminal Neuralgia
Ear Ringing/Tinnitus
Auditory Processing
Toe Walking
Sinus Headache
Tension Headache
Vertigo/Dizziness
Sensory Integration
Endocrine
Past
Hyperthyroid Issues
Hypothyroid Issues
Type 1 Diabetes
Type 2 Diabetes
Hair Loss
Menopausal
Menstrual Problems
Hot Flashes
Endometriosis
Polycystic Ovarian Syndrome
Hashimoto
Graves
Present
Hyperthyroid Issues
Hypothyroid Issues
Type 1 Diabetes
Type 2 Diabetes
Hair Loss
Menopausal
Menstrual Problems
Hot Flashes
Endometriosis
Polycystic Ovarian Syndrome
Hashimoto
Graves
Constitutional
Past
Weight Loss/Gain
Energy Level Low
Energy Level High
Difficulty Sleeping
Chronic Fatigue
General Malaise
Complusive Behavior
Behavior Issues
Learning Disabilities
Speech Delays
RLS
Pregnancy/Fertility
Obesity
Present
Weight Loss/Gain
Energy Level Low
Energy Level High
Difficulty Sleeping
Chronic Fatigue
General Malaise
Complusive Behavior
Behavior Issues
Learning Disabilities
Speech Delays
RLS
Pregnancy/Fertility
Obesity
Psychiatric
Past
Depression
Anxiety Disorder
Unusual Stress
OCD
Bipolar Disorder
Seasonal Affective Disorder
Mood Swings
Social Anxieties
Memory Loss
Night Tremors
Present
Depression
Anxiety Disorder
Unusual Stress
OCD
Bipolar Disorder
Seasonal Affective Disorder
Mood Swings
Social Anxieties
Memory Loss
Night Tremors
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