new ped ppw

It is a pleasure to welcome you to our family of happy and healthy chiropractic patients. Please let us know if there is any way we can make you and your family feel more comfortable. Many types of stressors (physical, mental, and chemical) can interfere with your child's growing brain, spine and nervous system. To help us serve you better, please complete the following information. We look forward to working with you to build better health for your family.
Child's Name*
(FIRST and LAST)
Today's Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Date
Weight*
(i.e. pounds/ounces)
MaleFemale
Height
(i.e. feet/inches)
Parent/Guardian Name*
Parent/Guardian Social Security Number:
(xxx-xx-xxxx)
Phone number*
Email*
example@example.com
Address*

Address

Street Address Line 2

CityState

Zip
Referred by
Reason for pursuing care*
Family history
Check any of the following conditions that currently apply

Car accidentHeadachesRefluxAllergiesDigestive problemsTemper TantrumsBed wettingEar InfectionsTongue/Lip TieChronic ColdsColicRecurring FeversADD/ADHDAsthmaSeizuresOther
Other doctors you've seen for this condition (Please include doctor's names and prior treatment)
Previous Chiropractic Care?*

YesNo
Last visit
Chiropractor's Name
Name of Pediatrician
Last visit
Are you satisfied with the care your child has received at the pediatrician?

YesNo
# of Doses of antibiotics your child has taken:
Past 6 months
Total lifetime
Present prescription drugs/ dosage?
Past prescription drugs/ dosage?
Over the counter drugs (Tylenol, cough syrup, laxatives,etc.)
Prenatal History
Name of Obstetrician/ Midwife*
Complications during pregnancy/ delivery (preeclampsia, GD, Low fluid) ?*

YesNo
If yes, please Explain:
Ultrasounds during pregnancy?*

YesNo
How many?
Medications taken during pregnancy/ delivery?*

YesNo
List
Cigarette/ Alcohol use during pregnancy?*

YesNo
Location of birth:*

HospitalBirthing CenterHome
Method of Delivery (circle all that apply):*

Vaginal with EpiduralVaginal without EpiduralEmergency C-SectionPlanned C-SectionVBAC
Length of Labor: (hours)
Pushed for: (minutes/hours)
Birth Intervention

InducedForcepsVacuumEpisiotomy
Gestational Age:
Baby was born at (ex. weeks and blank days.
Genetic disorders/disabilities?*

YesNo
If yes, list them here:
Birth Weight*
(pounds/ounces)
Birth Length
(inches)
APGAR Scores
Select one:*

SingletonTwinTriplet
Baby received (at birth)

Hepatitis B vaccineVitamin K injectionEye Ointment
Birth Trauma*

YesNo
If yes, Explain:
Feeding History
Breast Fed*

YesNo
If yes, how long?
Does baby prefer a breast side?*

YesNo
If yes, which side?
Formula Fed*

YesNo
If yes, how long?
If yes, type of Formula
Introduced to Solid Foods @ what age
Introduced to Cow's milk @ what age
Pain with Nursing:

NoYes
If pain with nursing please complete the pain scale. On a scale of 1-10 (1 being very little pain and 10 being the most painful)

12345678910
Food/ Juice allergies or intolerances*

YesNo
If yes, list here:
History of:

MastitisThrush (baby or mom)

Complete the chart below by marking in the appropriate box if baby experiences any of the below symptoms while nursing or taking a bottle.

	Breast	Bottle
Poor/ Shallow latch
Chomping/ Gumming
Milk Loss from Lips
Coughing/ Choking
Audible Gulping
Arching
Quick Fatigue
Tucked Upper Lip
Popping on/off
Labored breathing
Spit up
Riding the let down
Gagging

Developmental History

(to the best of your knowledge)
Your child's spine is vulnerable to stress and should routinely be checked by a Doctor of Chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference Spinal nerve interference can affect the following. At what age was your child able to:
Respond to stimuli
Hold head up
Cross Crawl
Walk alone
Talk
Stand alone
Sit up
Respond to visual stimuli
Has your child experienced any developmental goal delays?

NoYes
If yes, explain:
According to the National Safety Council, approximately 50% of children fall head first from a high place during their first year of life (i.e. a bed, changing table, down stairs)
Did your child have a fall similar to what was described above?*

NoYes
If yes, explain:
Other traumas not described above (bike wipeout, trampoline injury, etc.)?
Has your child been involved in any sports?*

YesNo
If yes, list here:
Has your child been seen by a physician on an emergency basis?*

YesNo
If yes, explain:
Lifestyle

(please check al that apply)
Does Your child:

eat healthy food organic products, etcdrink watertake probioticstake vitamins
List vitamins here
Does your child engage in exercise?*

nonemildmoderateheavydaily
Average tv viewing per week (hours)
Hobbies/ interests
Is there anything else you would like us to know about your child?
Does your child rest well while sleeping?*

yesno
# hours sleep/night*
I hereby give my consent for my child to be examined by the Chiropractor using chiropractic methods as seen fit.
Child name*
Parent/Guardian name*
Signature*

Clear
PHOTO RELEASE FORM
We love to have kids' pictures in our office! If you would allow us to have your child's picture in the office, please sign below.

For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by Southern Family Chiropractic LLC, or anyone authorized by Southern Family Chiropractic LLC, of any and all photographs/videos which were taken of my child, for the purposed of promotional TV, website, social media and/or print ad whatsoever, without further compensation to me. All negatives and positives, together with the prints shall constitute the property of Southern Family Chiropractic LLC, solely and completely. Any information voluntarily provided by a patient shall also be used in conjunction with the above listed information for purposes previously mentioned. Confidentially, in regards to any reported conditions, is also waived to the extent of information pertinent to the promotion material only. I authorize Southern Family Chiropractic LLC to share this information via their website and their Facebook/socia media including Twitter and Instagram, and for use in the office. All other unrelated patient information shall remain private and protected (according to Health Information and Privacy Act laws.
Signature

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Date

MonthDayYear
Date
AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES.

AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF THEPLEASE NOTE: IF X-RAYS ARE NECESSARY, THEY ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY.

THE DOCTORS OF SOUTHERN FAMILY CHIROPRACTIC DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE.

IF YOUR CHILD IS AN INFANT OR UNDER THE AGE OF FIVE, IT IS UNLIKELY THEY WILL NEED CHIROPRACTIC POSTURAL XRAYS. HOWEVER, PLEASE SIGN BELOW FOR FUTURE REFERENCE.

BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS
CHILDS NAME*
CHILD'S AGE*
PARENT/GARDIAN SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

Prenatal History

Feeding History

Developmental History

Lifestyle

PHOTO RELEASE FORM