New Pediatric Patient Registration Form

New Pediatric Patient Registration

Please fill in the form below.
Patient Information

Please answer each question to the best of your knowledge.
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Gender*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/ Guardian Name*

First NameLast Name
Parent Email Address*
Parent Phone Number*

Area CodePhone Number
Referred By (Pediatrician's Name):*

First NameLast Name
Reason for Visit
Primary Concern for Appointment*

Crisis ManagementEarly Problem DetectionMaximizing Natural Growth and Development
When and how did this health challenge begin?*
Since the problem(s) began, is it:

BetterWorseAbout the Same
Please indicate with an "X" where your child notices discomfort/problems occurring
How often does this problem occur?

ConstantIntermittentOccasionalCyclic
Does this problem interfere with your child's sleep?

YesNo
Does this problem interfere with your child's eating habits?

YesNo
What have you tried to improve your child's condition(s)?
Health History
Have you or your child been adjusted by a chiropractor before?*

YesNo
If yes, for what reason?
Pediatrician's Name:*

First NameLast Name
Date of Last Visit*

MonthDayYear
Date

Please list the number of

	In the last 6 months	In their lifetime
Antibiotic Doses Taken
Other Prescription Medications Taken
Over The Counter Medications Taken

Has your child ever been hospitalized, had surgery, or any major illnesses?*

YesNo
If yes, please explain:
What's your child vaccination history? Have they had any reactions to vaccines taken?
Have you withheld any vaccines?

YesNo
If yes, please explain:
Please check any of the following conditions your child may have now or has had previously:*

ColicEar InfectionsChronic ColdsAsthmaAllergiesSinus ProblemsSeizuresBed WettingHyperactivityTemper TantrumsSleeping ProblemsAnxiety/ADHDScoliosisHeadachesBack PainGrowing PainsCar AccidentDizzinessRecurring FeversDigestive ProblemsAcid RefluxPoor NutritionLimited ExerciseLow EnergyOther
Growth & Development
Was your child alert and responsive within 12 hours of delivery?*

YesNo
If no, please explain:
Was your child breastfed*

YesNo
If yes, for how long?
What age was formula introduced and which formula?

At what age did the child:

	AGE
Follow an object
Respond to sound
Crawl
Walk
Sit alone
Hold their head up
Teethe
Vocalize
Begin solid foods
Begin formula milk
Begin cow's milk

Does your child sleep on their:
How many hours per day do they sleep?
Do you consider their sleeping pattern to be normal?*

YesNo
If no, please explain:
Chemical Stresses
Please list any illnesses during your pregnancy:
Please list any supplements/medications taken during your pregnancy:
Did the mother have any ultrasounds?

YesNo
If yes, how many?
Please list any illnesses during your pregnancy:
Were there any invasive procedures during pregnancy (Amniocentesis, Chorionic Villi Sampling, etc.)?*

YesNo
If yes, please list them:
Are there any pets at home?

YesNo
Are there any smokers at home?

YesNo
Is the child's diet organic?

YesNo
Do you use "Green Products" for cleaning at home?

YesNo
How often does your child receive processed foods, sugar, gluten (flour), or dairy products?
Are you aware of the impact of nutrition on children's behavior?

YesNo
Would you like Nutrional information for your child?

YesNo
Psychosocial Stresses
Are/were there any lactation difficulties?

YesNo
If yes, please explain:
Are/were there any bonding difficulties?

YesNo
If yes, please explain:
Are/were there any behavioral difficulties?

YesNo
If yes, please explain:
Does your child have a lack of attention?

YesNo
Does your child have hyperactivity/restlessness?

YesNo
Does your child have compulsiveness?

YesNo
Is your child in daycare/school or home-schooled?

Home-schooledDaycare/School
What age did they begin education?
Any learning difficulties at daycare/school/home?

YesNo
Does your child have a nanny or regular sitter during the day?

YesNo
Any night terrors, sleepwalking, or difficulty sleeping?

YesNo
Any prolonged temper tantrums or separation anxiety?

YesNo
Do you feel that your child's social and emotional development is normal for their age?

YesNo
If no, please explain:
Authorization & Consent for Minor's Care
- I acknowledge and understand that a thorough evaluation must be performed to ensure the doctor provides suitable care for my child.
- I understand that by signing this form I hereby request and consent to the performance of a thorough evaluation.
- I understand that I may ask the doctor to stop the examination at any time.
- I also understand that by signing this form, the chiropractor continues to be obligated for best practices delivered in the child’s interests.
- I understand that I am directly and fully responsible to Align Your Spine Chiropractic, LLC for all fees associated with chiropractic care my child receives.
Guardian Signature*

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Date Signed*

MonthDayYear
Date
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New Pediatric Patient Registration

Patient Information

Reason for Visit

Health History

Growth & Development

Chemical Stresses

Psychosocial Stresses

Authorization & Consent for Minor's Care