Infant Intake Form
Part 2
Patient Information
Today's Date
*
-
Month
-
Day
Year
Date
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Emotional Stressors
THE FOLLOWING INFORMATIONIS EXTREMELY IMPORTANT BECAUSE MANY OF THE HEALTH CONCERNS THAT CHIROPRACTORS WORK WITH STEM FROM LIFESTYLE STRESSORS
Was the mother stressed out during pregnancy?
Yes
No
If yes, please explain:
Did the child's mother have any difficulty breastfeeding?
Yes
No
Did the child's mother have any difficulty bonding?
Yes
No
Does your child have any behavioral issues?
Yes
No
If yes, please explain:
Does your child have difficulty sleeping? (i.e. nightmares, sleepwalking, insomnia)
Yes
No
If yes, please explain:
Does your child attend daycare?
Yes
No
If yes, from what age?
Average time spent on screens per week (computer, TV, iPad, phone etc.):
Is your child nervous or has anyone suggested that your child is nervous?
Yes
No
Do you feel like your child's social and emotional development is normal for their age?
Yes
No
Rate your child'slevel of stress (Stress may be brought on by factors such as moving houses os schools, divorce, losing a family member etc.)
1
2
3
4
5
6
7
8
9
10
1 = little or no stress, 10 = Very High Stress
Chemical Stressors
During the pregnancy, did the mother smoke?
Yes
No
During the pregnancy, did the mother drink alcohol?
Yes
No
During the pregnancy, did the mother:
Yes
No
If yes, please explain
Smoke
Drink alcohol
Take Vitamins/supplements
Take recreational drugs
Become ill
Take medications
Receive ultasounds
Undergo investigations
(i.e. amniocentesis, CVS)
Was the child breastfed?
Yes
No
If yes, how long?
If your child has ever received formula, at what age was it introduced?
What brand of formula was introduced?
If your child has ever had solid food, at what age was it introduced?
If your child has ever had cow's milk, at what age was it introduced?
Does your child have any food allergies?
Yes
No
If yes, to what?
What does your child like to eat/favorite food?
What does your child regularly drink?
How often does your child receive processed foods, white sugar, gluten (wheat) and dairy in their diet?
Almost every meal
Daily
A few times per week
On weekends
On special occasion
Never
Are you aware of the impactof food/nutrition on your child's behavior?
Yes
No
Comment:
Rate your child's diet:
Excellent
Good
Poor
Did you choose to vaccinate your child?
Yes
No
If yes, what type of schedule did you use?
Full Schedule
Delayed Schedule
Reduced Schedule
Homeopathic Vaccines
Date of last vaccination:
Did you notice any changes in your child after their vaccinations?
Yes
No
If so, which of the following did you notice? (Check all that apply)
Fever
Inconsolable crying
Irritability
Lethargy/fatigue
Aching
Drowsiness
Bowel disturbances
Feeding disturbances
Neurological regression
How many courses of antibiotics has your child received in their lifetime?
When was the last course take and why?
Any other chemical (medications) in the last 6 months?
Are there pets at home?
Yes
No
Are there smokers in the home?
Yes
No
Physical Stressors
Were there any traumas to the mother during pregnancy (i.e. falls, accidents)?
Yes
No
If yes, please explain:
Has your child had any falls (from a height) since birth (i.e. changing table, couch bed)?
Yes
No
If yes, please explain:
Any traumas resulting in bruises, cuts, stitches or fractures?
Yes
No
Does your child have difficulty with co-ordination?
Yes
No
If you could improve one aspect of your child's health or behavior, what would it be?
Financial and Insurance Information
Who is responsible for this account
*
Relationship to patient:
*
Is this condition due to an accident?
*
Yes
No
Type of accident:
Auto
Work
Home
Other
To whom have you made a report of your accident:
Auto Insurance
Employer
Workers Comp
Other
Insurance Information
Insurance Company
Policy Number
Policy Holder Name
Policy Holder DOB
Relationship
Primary Insurance
I have read the above information and certify it to be true and correct to the best of my knowledge and hereby authorize Active Family Chiropractic to provide me with chiropractic care, in accordance with this state's statutes.
Name
First Name
Last Name
Signature
Save
Submit
Submit
Should be Empty: