PED_INTAKE

It is a pleasure to welcome you to our family of happy and healthy chiropractic families. 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: *
Today's Date: *

Month Day Year
Date
Birth Date: *

Month Day Year
Date
*

male female
Weight: *
Height:
Parent/Guardian Name: *
Phone number: *
Address *

Address

Street Address Line 2

City State

Zip
Parent/Guardian Social Security Number:
Referred by: *
Reason for pursuing care: *
Family history:
Check any of the following conditions that currently apply: *

ADHD/ADD Scoliosis Ear Infections Chronic Colds Headaches Allergies Digestive Issues Recurring Fevers Colic Reflux Bed Wetting Temper Tantrums Seizures Asthma Car Accident
If car accident please explain:
Other doctors seen for this condition (Please include doctor’s names and prior treatment):
Name of Pediatrician: *
Last visit: *
Are you satisfied with the care your child has received at the pediatrician? *

Yes No
Previous Chiropractic Care? *

Yes No
# of Doses of antibiotics your child has taken in the past 6 months: *
# of Doses of antibiotics your child has taken in 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? *

Yes No
If yes, Explain:
Ultrasounds during pregnancy? *

Yes No
If yes, How many?
Medications taken during pregnancy/ delivery? *

Yes No
If yes, list them here:
Cigarette/ Alcohol use during pregnancy? *

Yes No
Location of birth: *

Hospital Birth Center Home
Birth Intervention: *

Induced Forceps Vacuum C-Section n/a
If Caesarian Section, was it:

Planned Emergency
Genetic disorders/disabilities? *

Yes No
If yes, List:
Final APGAR Score if known:
please enter a number 1-10
Breast Fed: *

Yes No
If yes, how long?
Formula Fed: *

Yes No
If yes, how long?
Formula Brand?
Introduced solid food at what age?
How many months
Introduced Cow's milk at what age?
How many months
Food/ Juice allergies or intolerances: *

Yes No
If yes, list here:
(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
Talk
Walk alone
Stand alone
Sit up
Respond to visual stimuli
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? *

Yes No
If yes, please explain:
Other traumas not described above (bike wipeout, trampoline injury, etc.)?
Has your child been involved in any sports? *

Yes No
If yes, please list:
Has your child been seen by a physician on an emergency basis? *

Yes No
If yes, please explain:
Does your child (mark all that apply) *

Eat healthy food organic products, etc Drink water Take probiotics Take vitamins n/a
How often does your child exercise: (choose one) *

None Daily Multiple times a week Few times a month
Hobbies/ interests:
Is there anything else you would like us to know about your child?
Parent/Guardian name: *
Signature: *

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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/social 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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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 THE X-RAYS IN OUR FILES.

PLEASE 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/GUARDIAN SIGNATURE

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PHOTO RELEASE FORM