Pediatric Questionnaire
CONFIDENTIAL PATIENT INFORMATION
Permission to send SMS text messages
*
Yes
No
Child's Name
First Name
Last Name
Parent/Guardian Names
Date of Birth
-
Month
-
Day
Year
Date
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Email
example@example.com
Gender
Male
Female
How did you hear about us?
Who is your primary care physician?
Is your child receiving care from any other health professionals? (Yes/No) If yes, please name them and their specialty:
Is your child receiving care from any other health professionals? (Yes/No) If yes, please name them and their specialty:
Please list any drugs/medications/vitamins/herbs/other that your child is taking:
CURRENT HEALTH CONDITIONS
What reason brought your child to our office today?
*
When did the condition first begin?
How did the problem start?
Suddenly
Gradually
Post-Injury
Is this condition:
Getting worse
Improving
Intermittent
Constant
Unsure
What makes the problem better?
What makes the problem worse?
HEALTH GOALS FOR YOUR CHILD
Has your child ever received chiropractic care before? If yes, please explain:
What are your top three health goals for your child?
*
1. 2. 3.
What would you like to gain from chiropractic care?
Resolve existing condition
Overall wellness
Both
Have you ever visited a chiropractor?
If yes, what is their name?
What is their speciality?
Pediatric Specialist
Pain relief
Physical Therapy & Rehab
Nutritional
Subluxation-based
Other
PREGNANCY & FERTILITY HISTORY
Please tell us about your pregnancy
Any fertility issues? (Yes/No) If yes, please explain:
Did mother smoke? (Yes/No) If yes, how many per week?
Did mother drink? (Yes/No) If yes, how many per week?
Did mother exercise? (Yes/No) If yes, please explain:
Was mother ill? (Yes/No) If yes, please explain:
Any ultrasounds? (Yes/No) If yes, please explain:
Please explain any notable episodes of mental or physical stress during your pregnancy:
Please explain any other concerns or notable remarks about your child's conception or pregnancy:
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LABOR & DELIVERY HISTORY
Child's birth was:
Natural (no drugs or intervention)
Scheduled C-Section
Emergency C-Section
Child's birth was:
At home
At a birthing center
At a hospital
Doctor/Obstetrician/Midwife's name:
Gestation length (weeks):
Born at how many weeks?
Please check any applicable interventions or complications:
Breech
Induction
Pain meds
Epidural
Episiotomy
Foreceps
Vacuum extraction
Please describe any other concerns or notable remarks about your child's labor and/or delivery:
Child's birth weight:
lbs. oz.
Child's birth length:
inches
APGAR score at birth:
APGAR score after 5 minutes:
Current Weight
Pounds
Current Height
GROWTH & DEVELOPMENT HISTORY
Is/was your child breastfed? (Yes/No)
If yes, how long?
Difficulty breastfeeding? (Yes/No)
Did they ever use formula? (Yes/No)
If yes, what age did they start formula? What type?
Did/does your child ever suffer from colic, reflux, or constipation as an infant? (Yes/No) If yes, please explain:
Did/does your child frequently arch their neck/back, feel stiff, or bang their head? (Yes/No) If yes, please explain:
Best you can recall, at what age did the child:
Respond to sound: Follow an object: Hold their head up: Start cutting teeth:
Best you can recall, at what age did the child:
Sit alone: Crawl: Walk: Begin cow's milk: Begin solid foods:
Please list any food intolerances or allergies, and when they began:
Please list your child's hospitalization and surgical history, including the year:
Please list any major injuries, accidents, falls and/or fractures your child has sustained in his/her lifetime, including the year:
Have you chosen to vaccinate your child?
No
Yes, on a delayed or selective schedule
Yes, on schedule
- If yes, please list any vaccination reactions:
Has your child received any antibiotics? (Yes/No) If yes, how many times and list reason:
Night terrors or difficulty sleeping? (Yes/No) If yes, please explain:
Behavioral, social, or emotional issues? (Yes/No) If yes, please explain:
How many hours per day does your child typically spend watching a TV, computer, tablet or phone?
How would you describe your child's diet?
Mostly whole, organic foods
Pretty average
High amount of processed foods
ACKNOWLEDGEMENT & CONSENT
Parent/Guardian's Signature
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