PediatricNewPatient

Pediatric Health Questionnaire
Name*

First Name Last Name
Birthdate*

MonthDay Year
Date
Age*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Weight
Height
Phone Number*
Email*
example@example.com
Purpose for your visit?*
How long has this condition been present?
Has the condition improved/worsened?
Other Doctors seen for this condition? yes/no
If yes, Doctor's name and prior treatment:
Name of Pediatrician/Family Doctor:
Doctor*
Last Visit*
Siblings Names and Ages:*
CHIROPRACTIC EXPERIENCE
Who may we thank for referring you to our office?*
Has your child ever been evaluated or adjusted by a chiropractor?*
If yes, what was the reason for the visit?
Name of Chiropractor and Date of Last Visit:
GENERAL HISTORY
Check any of the following conditions your child has suffered from during the past six months:

asthma/allergiesgrowing painsfailure to thrivebed wettingconstipationcar accidentLearning disabilitiescolicear infectionsscoliosisseizureschronic illnessheadachesdigestive problemsADHDrecurring feversweight lossspeech delaysToe walkingTemper tantrumAutism
Family History of Chronic Illness: Please list any heart disease, cancer, diabetes, autoimmune disease,etc. Family Member/Issue:*
Family Member/Issue:
Family Member/Issue:
Number of doses of antibiotics your child has taken:
Reason for antibiotics:
Other prescription medications your child has taken:
Reason for prescription:
List any supplements your child is taking
Is your child vaccinated?*

yesno:alternate schedule:
Did your child have any of the following reactions to vaccinations?

nonefeverrashpain at the injection sitefatigueseizuresvomitingdiarrheadevelopment delayexcessive cryingOther
Has your child contracted any childhood disease (i.e chicken pox, mumps, measles, etc) If so, please list:*
PRENATAL HISTORY
Name of Obstetrician:
Midwife
Complications during pregnancy? yes/no*

noyes
If yes, please list
Ultasounds during pregnancy?*

noyes
If yes, how many
Medications during pregnancy?*

noyes
If yes, please list:
Flu shot or DTAP during pregnancy?*

noyes
Which one?
Cigarette/alcohol during pregnancy?*

noyes
Location of Birth*

hospitalbirthing centerhome
How long were you in labor?*
Birth interventions

forcepsvacuum extractionepiduralpain medsprotocinC-section, planned or emergency?
Complications during delivery?
Genetic disorders or disabilities:
Birth weight and length*
APGAR scores
Did your child show any of the following signs of birth trauma:

bruisingstuck in the birth canalcord around the neckrespiratory distresshead rotated to one sideodd shaped head
NUTRITIONAL AND ACTIVITY HISTORY:
Breast fed? if yes, how long?*
Any difficulty?
Formula fed? Yes/no. If yes, how long?*
Type?
Introduced to solids at _______ months old?*
Introduced to cow's milk at _______ months/years?*
Food/Juice allergies/intolerances:*
Does your child eat any of the following

eggsdairygluten/wheatsoysugarcaffeine
List your child's 3 favorite foods:*
Does your child drink water? If so, how many glasses a day?*
Does your child play outside? List their activities:*
Does your child watch TV? If so, how many hours a week?*
How many hours of sleep does your child get a night?*
Quality of sleep? Good, fair, poor:*
Does your child take naps? Length of naps?*
GROWTH AND DEVELOPMENT
During the following times 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 (nerve interference) At what age was your child able to:
Respond to stimuli*
Cross Crawl*
Sit up*
Hold head up*
Stand alone*
Walk alone*
The National Safety Council, approximately 50% of children fell head first from a high place during their first year of life (i.e bed, changing tables, stairs, etc) Was this the case for your child?*

yesno
Has your child been involved in any high impact or contact type sports?*

noyes
Has your child ever been involved in a car accident*

yesno
Any prior surgery? Yes/No. If yes, please list:*
If there is anything else you would like us to know about your child please list it below
AUTHORIZATION FOR CARE OF A MINOR

I hereby authorize Circle of Life Chiropractic and its Doctors to administer care to my son/daughter as they deem necessary. I clearly understand and agree that I am personally responsible for payment of all services rendered by this office.
Parent/Guardian Printed Name*
Parent/Guardian Signature*

Clear
Date*

MonthDay Year
Date
I authorize the release of any and all medical records or other information necessary to process claims. I also request payment of benefits be made directly to Circle of Life Chiropractic. I am consenting to signing an open sign-in sheet every visit on behalf of my son/daughter and I understand that anyone who enter the office will be able to view his/her name on this sheet. The statements made on this form are accurate to the best of my recollection.
Parent/Guardian Signature*

Clear
Date*

MonthDay Year
Date
24 HOUR CANCELLATION POLICY
Due to the high volume of appointments and our commitment to having your wait time remain short, we have decided to implement a 24 hour cancellation policy. This allows us to fit everyone into our schedule that needs to be seen while respecting your time. We've never wanted to be an office that double books appointments, therefore causing you to wait 20+ minutes to be seen. However, our schedule is often full and the last minute cancellations are unfair to those needing appointments whom we've turned away. Every family member that is cancelled less than 24 hours in advance will be charged a $50 cancellation fee. We appreciate you and want to continue to serve you at a high level.

To cancel or reschedule your appointment, please call us at 732-295-4000 or text us at 732-701-7407. If you cannot reach us or it is outside office hours please leave a detailed message with your name and phone number. We will return your call promptly.

By signing below, you acknowledge that you have read and understand the cancellation policy.
Name*
Signature*

Clear
Date*

MonthDay Year
Date
Should be Empty:

CHIROPRACTIC EXPERIENCE

GENERAL HISTORY

PRENATAL HISTORY

NUTRITIONAL AND ACTIVITY HISTORY:

GROWTH AND DEVELOPMENT

24 HOUR CANCELLATION POLICY