Child Health History
Chiropractic Family Wellness Center
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Info
Mother's Name and Phone Number
Mother's Occupation
Father's Name and Phone Number
Father's Occupation
Child Info
Reason for Seeking Chiropractic Care
Prior Chiropractic Care?
Yes
No
Any Other Family Members in Chiropractic Care?
Yes
No
If yes, who and what relation?
Physical Stress
Please tell us about any physical stress experienced in life so far;
Place of Birth
Home
Hospital
Birth Center
Other
Medication during birth
Anesthesia
Epidural
Pitocin
Other
Assisting tools/ methods
Forceps
Vacuum
C-Section
Other
Has your child ever been knocked unconscious?
Yes
No
List any impacts, falls, injuries, or traumas that have happened which may have affected your body and/ or spine
Please select any and all that apply
Involved in a car accident
Hospitalized
Surgeries
Spinal Tap
Neck Collar
Traction
Spinal Brace
Heel Lift
Any current prescription or over the counter medications (or within the past year?)
Yes
No
If yes, please list
If under the care of PCP, please list name and office
Any exposure to smoke?
Yes
No
Sometimes
Please give vaccination status
Fully
Partially
Not
At what age did vaccines (if any) occur?
Emotional Stress
Please select all the apply
General childhood stress
School stress
Family stress
Loss of a loved one
Change in lifestyle
Stress from being sick
Please list any topics of concern you would like to discuss today
Financial/ Insurance Disclaimer
We are a cash practice and do not accept accident insurance, bodily injury or workman's compensation cases. We offer a creative and affordable fee system and can provide receipts of services rendered or documentation of medical necessity for those whose insurance can directly reimburse them.
I understand that payment is due at the time of service (signature of parent or guardian if under 18)
Submit
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