Pediatric Patient Questionnaire
CONFIDENTIAL PATIENT INFORMATION
Child's Name:
First Name
Last Name
Parent/ Guardian Name(s):
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Other Phone:
Please enter a valid phone number.
Child's Sex:
Male
Female
Email:
example@example.com
Child's SS#:
Birthdate:
-
Month
-
Day
Year
Date
Age:
How did you hear about us?
Weight:
Height:
Who is primary care physician?
Is your child receiving care from any other health professionals?
Yes
No
If yes, please name them and their specialty:
Please list any drugs/medications/vitamins/herbs/other that your child is taking:
CURRENT HEALTH CONDITIONS
What health condition(s) bring your child to be evaluated by a chiropractor?
When did the condition first begin?
How did the problem start?
Suddenly
Gradually
Post-Injury
Has your child ever received care for this condition before?
Yes
No
If yes, please explaining:
Is this condition:
Getting worse
Improving
Intermittent
Constant
Unsure
What makes the problem better?
What makes the problem worse?
HEALTH GOALS FOR YOUR CHILD
What are your top three health goals for your child?
What would you like to gain from chiropractic care?
Resolve existing condition
Overall wellness
Both
Have you ever visited a chiropractor?
Yes
No
If yes, what is their name?
What is their speciality?
Pain Relief
Physical Therapy & Rehab
Nutritional
Subluxation-based
Other
PREGNANCY & FERTILITY HISTORY
Please tell us about your pregnancy
Any fertility issues?
Yes
No
If yes, please explain:
Did mother smoke?
Yes
No
If yes, how many per week?
Did mother drink?
Yes
No
If yes, how many per week?
Did mother exercise?
Yes
No
If yes, please explain:
Was mother ill?
Yes
No
If yes, please explain:
Any ultrasounds?
Yes
No
If yes, please explain:
Please explain any other concerns or notable remarks about your child's conception or pregnacy:
Please explain any notable episodes of mental or physical stress during your pregnancy:
LABOR & DELIVERY HISTORY
Child's birth was:
Natural vaginal birth
Scheduled C-section
Emergency C-section
At how many weeks was your child born?
Childs birth was:
At home
At a birthing center
At a hospital
Other
Doctor/Obstetrician's Name:
Please check any applicable interventions or complications:
Breech
Induction
Pain meds
Epidural
Episiotomy
Vacuum extraction
Forceps
Other
Please describe any other concerns or notable remarks about your child's labor and/or delivery.
Child's birth weight:
Child's birth height:
APGAR score at birth:
APGAR score after 5 minutes:
GROWTH & DEVELOPMENT HISTORY
Is/was your child breastfed?
Yes
No
If yes, how long?
Difficulty with breastfeeding?
Yes
No
Did they ever use formula?
Yes
No
If yes, at what age?
If yes, what type?
Did/does your child ever suffer from colic, reflux, or constipation as an infant?
Yes
No
If yes, please explain:
Did/does your child frequently arch their neck/back, feel stiff, or bang their head?
Yes
No
If yes, please explain:
At what age did the child:
Age
Follow an object:
Respond to sound:
Walk:
Crawl:
Sit alone:
Hold their head up:
Begin cow's milk:
Teethe:
Vocalize:
Begin solid foods:
Please list any food intolerance or allergies, and when they began:
Please list your child's hospitalization and surgical history, including the year:
Please list any major injuries, accidents, falls and/or fractures your child has sustained in his/her lifetime, including the year:
Have you chosen to vaccinate your child?
No
Yes, on a delayed or selective schedule
Yes, on schedule
If yes, please list any vaccination reactions:
Has your child received any antibiotics?
Yes
No
If yes, how many times and list reason:
Night terrors or difficult/ sleeping?
Yes
No
If yes, please explain:
Behavioral, social or emotional issues?
Yes
No
If yes, please explain:
How many hours per day does your child typically spend watching a TV, computer, tablet or phone?
How would you describe your Childs diet?
Mostly whole, organic foods
Pretty average
High amount of processed foods
ACKNOWLEDGEMENT & CONSENT
Patient Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: