Pediatric Patient Questionnaire

Child's Name

First Name Last Name

Parent/Guardian Names

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone

Area Code Phone Number

Home Phone

Area Code Phone Number

Email

example@example.com

Date of Birth

Date

Age

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:

Please list any drugs/medications/vitamins/herbs/other that your child is taking:

What health condition(s) bring your child to be evaluated by a chiropractor?

When did the condition first begin?

How did the problem start?

Suddenly Gradually Post-Injury

Has your child ever received chiropractic care before? If yes, please explain:

Is this condition:

Getting worse Improving Intermittent Constant Unsure

What makes the problem better?

What makes the problem worse?

What are your top three health goals for your child?

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?

Pain relief Physical Therapy & Rehab Nutritional Subluxation-based Other

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:

Pediatric Patient Questionnaire

CONFIDENTIAL PATIENT INFORMATION

CURRENT HEALTH CONDITIONS

HEALTH GOALS FOR YOUR CHILD

PREGNANCY & FERTILITY HISTORY

LABOR & DELIVERY HISTORY

GROWTH & DEVELOPMENT HISTORY

ACKNOWLEDGEMENT & CONSENT