brookevillechiropractic.com - CHILDREN’S CHIROPRACTIC HISTORY

CHILDREN’S CHIROPRACTIC HISTORY
Patient’s Name:

First NameLast Name
Today’s Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child’s DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mom’s Name:
Dad’s Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Co:
Insured’s Name:
Insured’s Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured’s SS#
Who Referred you:
Sex:
Number of Siblings:
POSTNATAL AND INFANT HISTORY
Has your child ever suffered from?
Purpose of visit:
Who is your child’s pediatrician?
Pediatrician phone:
Please enter a valid phone number.Format: (000) 000-0000.
Date of last visit:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you satisfied with the care you receive there?
Birth Height
Birth Weight
Current Height
Current Weight
Apgar scores:
Was there a presence of
Was baby ever in NICU?
If yes, why?
Congenital anomalies/defects?
Was any medication given to baby at birth?
If yes, why?
Is your child taking any medication now?
Was your child
For how long?
Did your child show any sensitivities to formula? (Reflux, eczema, arching back, spit up)?
What age did you introduce solid foods to your child _____months
First solid food:
Introduced to cow’s milk at what age?
Any known food allergies:
# of antibiotics prescribed:
During the past 6 months?
Reason:
Total during baby’s lifetime?
Reason:
PRENATAL HISTORY
Problems during pregnancy:
Medications during pregnancy:
OB/Gyn. Name:
OB/Gyn. Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
BIRTH EXPERIENCE
Birth location:

Other
Birth attendants:

Other
Mediations during labor / delivery (including IV antibiotics)?
If yes, describe:
Did you have an epidural?
If yes, describe:
Was Pitocin used to induce/speed up labor?
Problems during labor:
Was your delivery
If C-section, was it
Why?
How long was your labor:
How long was pushing:
If it was vaginal, were any used during delivery?

Other
PHYSICAL TRAUMAS
Has your child ever fallen from a high place?
Has your child ever been involved in a motor vehicle accident?
Has your child ever been seen on an emergency basis?
Has your child ever broken any bones?
Has your child ever had any previous surgeries?
DEVELOPMENTAL HISTORY
At what age was your child able to?
Respond to Sound
e.g. 2
Cross Crawl
e.g. 2
Respond to Visual Stimuli
e.g. 2
Stand Up
e.g. 2
Hold Head Up
e.g. 2
Walk alone
e.g. 2
Sit Up
e.g. 2
I hereby authorize this clinic and its Doctor(s) to administer care as they so deem necessary to My Son / Daughter / Ward.
Signed:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature on file and authorization to release medical information:

I HEREBY AUTHORIZE PAYMENT OF INSURANCE BENEFITS DIRECTLY TO THE DOCTOR FOR SERVICES PROVIDED. I FURTHER AUTHORIZE THE DOCTOR TO RELEASE ANY INFORMATION REQUIRED TO PROCESS INSURANCE CLAIMS.
Signed:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

CHILDREN’S CHIROPRACTIC HISTORY

POSTNATAL AND INFANT HISTORY

PRENATAL HISTORY

BIRTH EXPERIENCE

PHYSICAL TRAUMAS

DEVELOPMENTAL HISTORY