Pediatric Form

General Questions/ Prenatal History:

Birthing Intervention:

Normal VaginalForcepsCesareanSuction Cap or Vacuum

Is your child adopted?

YesNo

Problems during pregnancy

Problems during labor/delivery

Immunization history

Number of doses of antibiotics your child has taken: During the past 6 monthsType a label During his/her lifetimeType a label

At what age, if ever, did this child suffer from the following childhood diseases?

	Check	Age
Chickenpox
Mumps
Measles_
Rubella
Rubeola_
Whooping cough
Other

Present Complaint(s)

When did this begin?

Was there an accident/injury involved?

YesNo

Has your child had any past treatment for this complaint?

YesNo

Describe:

Has this child ever suffered from

If allergies

If Other

Has this child ever suffered from the following spinal traumas?

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. bed, changing table, down stairs, etc.). Was this the case with your child?

YesNo

Explain

Has this child ever sustained an injury playing organized sports? If yes, please explain:

Has this child ever sustained injuries in an auto accident? If yes, please explain:

Has this child ever broken/fractured any bones? Explain:

Has this child ever received stiches not related to surgery:

Other traumas not described above:

Surgeries:

Medications:

Present history:

Purpose of this appointment:

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Pediatric Intake Form