Pediatric Intake Form

Pediatric Intake Form

1230 George Towne Drive, Suite C, Pewaukee, WI 53072
Child's Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
DOB:

MonthDayYear
Date
Child's Sex:

MaleFemale
Parent/Guardian's Name:

First NameLast Name
Parent/Guardian's Phone:

Area CodePhone Number
Parent/Guardian's Email:
example@example.com
What are the primary health concerns for your child?
Is the purpose of this appointment related to any of the following? Please check all that apply.

Wellness check-upBirth traumaSports InjuryAuto InjuryFallChronic discomfort or illnessOther
Is there a history of any problems the doctor should know about? Please check all that apply.

Reflux/colicSleeping problemsEar infectionsADD/ADHDAutismTorticollisCerebral PalsyBed wettingAllergiesAnxiety/DepressionOther
Please list any drugs/medications/vitamins/herbs/other your child is taking:
Please list any surgeries your child has had:
During pregnancy, did the mother do any of the following? Check all that apply:

Take medicationSmoke/consume alcoholExperience illness
Labor was (check all that apply):

VaginalC-sectionDoctor-assistedChemically inducedPremature
At how many weeks was your child born?
In weeks
Weight at birth:
During delivery, were any of the following used? Check all that apply:

Vacuum extractionForcepsPulling/twistingOther
How long did the labor last?
Was the mother given medication during labor?
What are your top three health goals for your child?
What would you like to gain from chiropractic care?

Resolve existing condtionOverall wellnessBoth to resolve existing condition and improve overall wellness
I, being parent or legal guardian of this minor, hereby authorize, request, and direct the doctor to perform any examination, neuro INSiGHT scans, x-rays (ages 7 and older), and chiropractic care that he/she deems necessary.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: