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 NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Business Phone Number

Area CodePhone 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?

constantcomes and goesworse at nightworse in morninggetting bettergetting worseoccasional
What does it feel like?

dullsharpburningtinglingthrobbingtightpins/needlesreferring/radiating
Check all that applies; I have:

night painnight sweatsunexplained weight loss
My problem interferes with:

sleepfamily timesittingwalkinghobbies

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 midwifevacuum/forceps extractionhad an epiduralhospital birthdifficult birthC-sectionInducedhealthy 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:

diabeteshigh blood pressurecancer
I have had these past traumas:

fall (s)sports injury (s)car accident (s)fall out of crib/bedplayed in a jolly jumpersleep on stomach
Please check all that apply:

Low Back PainPain Between ShouldersNeck painHeadaches/MigrainesTiredness/FatigueTight MusclesTension in Shoulders/Mid-backStressDigestive IssuesNumbness/Tingling in Arms/HandsNumbness/Tingling in Legs/FeetDizzinessVertigoRinging in EarsFrequent ColdsThyroid ProblemsDepressionAnxietyAsthma/AllergiesMenstrual CrampsMood SwingsHeartburnWalking/Balance ProblemsBed WettingFrequent Ear InfectionsFrequent FeversSleeping ProblemsFrequent ColdsGrowing 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 foodsI sleep poorlyI consume coffeeI exercise regularlyI eat healthyI drink plenty of waterI sleep well
Any hospital stays? When and Why?
Any surgeries?
Any drug reactions/allergies?
What is the main purpose for this appointment?
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

MonthDayYear
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