Atlas Chiropractic _ Patient Intake Form _ PEDIA

  • PEDIATRIC HISTORY FORM

  • It is a pleasure to welcome you to our family of happy and healthy chiropractic practice members. 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 brains, spine and overall 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.

  • Birth Date
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  • Gender
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  • Reason for pursuing care
  • Other doctors seen for this condition?
  • Check any of the following conditions that currently apply:
  • Previous Chiropractic Care
  • Last visit
     - -
  • Last visit
     - -

  • Prenatal History

  • Complications during pregnancy/ delivery?
  • Ultrasounds during pregnancy?
  • Medications taken during pregnancy/ delivery
  • Cigarette/Alcohol use during pregnancy?
  • Location of birth
  • Birth Intervention
  • If Caesarian Section, was it
  • Genetic disorders/ disabilities?

  • FEEDING HISTORY

  • Breast Fed
  • Formula Fed
  • Food/Juice allergies or intolerance's

  • Developmental History

    Your child’s spine is most vulnerable to stress and should routinely be checked by a doctor of chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference).
  • Rows

  • 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?
  • Has your child been involved in any sports?
  • Has your child been seen by a physician on an emergency basis?

  • Lifestyle

  • Does your child
  • Should be Empty: