CHILD NEW PATIENT HEALTH HISTORY FORM

CHILD NEW PATIENT HEALTH HISTORY FORM

Please complete form in full. Parent signature required for those under 18 years of age.
Patient Data
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Age
Gender
Address

Street Address

Street Address Line 2

City Province

Postal Code
Cell Phone Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Business Phone Number

Area Code Phone Number
Your Best Email
example@example.com
Family Physician
Previous Chiropractor?
Why did you discontinue?
Who should we thank for referring you to our office?
Family member or friend? Website? Another Health Provider? Google? YouTube? Facebook? Instagram? Other?
Current Health Profile
Your Main Complaint:
How long have you suffered with this?
What makes it better?
What is the pattern?

constant comes and goes worse at night worse in morning getting better getting worse occasional
What does it feel like?

dull sharp burning tingling throbbing tight pins/needles referring/radiating
Check all that applies; I have:

night pain night sweats unexplained weight loss
My problem interferes with:

sleep family time sitting walking hobbies

Please rate the intensity of your problem (0=feeling great; 10=worst imaginable)

	0	1	2	3	4	5	6	7	8	9	10

0 is Feeling Great, 10 is Worst Imaginable

Check all that apply with respect to birth process (for moms):

used a midwife vacuum/forceps extraction had an epidural hospital birth difficult birth C-section Induced healthy birth
Who else have you seen for your problem?
Any secondary complaints?
How long have you suffered with this?
What makes it better?
What makes it worse?
How did it start?

Please rate the intensity of your problem (0=feeling great; 10=worst imaginable)

	0	1	2	3	4	5	6	7	8	9	10

0 is Feeling Great, 10 is Worst Imaginable

Health History
Please list any medications you are currently taking.
Please list any supplements you are taking.
Please list any past surgeries.
Any past motor vehicle accidents? Date?
My past health history has been:
I have or have suffered from:

diabetes high blood pressure cancer
I have had these past traumas:

fall (s) sports injury (s) car accident (s) fall out of crib/bed played in a jolly jumper sleep on stomach
Please check all that apply:

Low Back Pain Pain Between Shoulders Neck pain Headaches/Migraines Tiredness/Fatigue Tight Muscles Tension in Shoulders/Mid-back Stress Digestive Issues Numbness/Tingling in Arms/Hands Numbness/Tingling in Legs/Feet Dizziness Vertigo Ringing in Ears Frequent Colds Thyroid Problems Depression Anxiety Asthma/Allergies Menstrual Cramps Mood Swings Heartburn Walking/Balance Problems Bed Wetting Frequent Ear Infections Frequent Fevers Sleeping Problems Frequent Colds Growing Pains
What can't you (your child) do right now that is preventing you from fully enjoying your life?
What are your (your childs) short and long-term health goals?
Rate the importance of correcting your problem (0=not important, 10=most important
Pick number between 0 and 10
Lifestyle/Habits
Check all that apply:

I consume soft drinks/sugary foods I sleep poorly I consume coffee I exercise regularly I eat healthy I drink plenty of water I sleep well
Any hospital stays? When and Why?
Any surgeries?
Any drug reactions/allergies?
What is the main purpose for this appointment?
COVID-19 SCREENING

Please confirm that you DO NOT:

1) Presenting with fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing?

2) Have not had any close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days?

3) Do not have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

4) Do not have two (2) or more of the following symptoms: sore throat, runny nose/sneezing, nasal congestion, hoarse voice, difficulty swallowing, decrease or loss of sense of smell, chills, headaches, unexplained fatigue/malaise, diarrhea, abdominal pain, or nausea/vomiting?

5) If you are over 65 years of age, are you experiencing any of the following: delirium, falls, acute functional decline, or worsening of chronic conditions?
I CONFIRM THE ABOVE TO BE TRUE.

Please check if you agree with above.
I give my consent to have the doctor(s) perform an exam and take any x-rays that are deemed appropriate to better understand my problem and monitor my progress. Also, I consent to use of my email for office announcements and/or emailing/texting reminders for my visits.
Print Name:
Signature:

Clear
Parent Signature (if child under 18 years of age)

Clear
Date

Month Day Year
Date
Chiropractic on Eagle, Dr. Jon Saunders 407 Eagle Street, Newmarket, ON L3Y1K5 905.953.1028 www.chirofirst.ca
Should be Empty:

CHILD NEW PATIENT HEALTH HISTORY FORM

Patient Data

Current Health Profile

Health History

Lifestyle/Habits