Be Rooted Chiro Pediatric Health History Form

Pediatric Health History Form
Today's Date

MonthDayYear
Date
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Child's Age*
Child's gender?*
Do you have any other immediate household family members who are patients here? If yes please list them.
Parent's Name*

First NameLast Name
Cell Phone*
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
Text Reminders
Name of Service Provider
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purpose of todays visit?
Who referred you here?
Other Doctors seen for this condition? Please list name and prior treatment:
Has your child ever suffered from:

Ear infectionsdigestive problemsauto accidentheadachesashma/allergiesbed wettingchronic coldsgrowing/back paincolicseizuresrecurring feversscoliosisADHDtemper tantrumsother
Family History
Previous Chiropractor, Date of last visit and reason:
Where you satisfied?

YesNo
Why?
Previous/Current Pediatrician, date of last visit and reason
Number of antibiotics your child has taken in the past six months and total liftime?
Vaccination History

Up to DatePartially VaccinatedNo Vaccinations
Feeding History
Breast Fed:
If yes, how long?
Formula
If yes, how long?
Introduced to Solids at how many months?
Introduced to Cow's milk at how many months?
Food/Juice Allergies or Tolerances
If yes, please list?
Other allergies or tolerances
If yes, please list?
Number of hours sleeping per night:
Quality of sleep:
Prenatal History
Name of Obstetrician/Midwife:
Birth Intervention:
Ultrasounds during pregnancy:

YesNo
If yes, how many?
Medications during pregnancy/delivery?

YesNo
If yes, please list?
Cigarette/Alcohol use during pregnancy

YesNo
If yes, how much and how often?
Childhood Infections
Chicken Pox

YesNo
If yes, what age?
Measles (Rubeola)

YesNo
If yes, what age?
Whooping Cough

YesNo
If yes, what age?
Rubella

YesNo
If yes, what age?
Other

YesNo
If yes, list infection and what age?
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. a bed, changing table, down the stairs, etc.) Did this happen with your child? If yes, please explain:
Has your child ever been involved in a car accident? Please explain
Date

MonthDayYear
Date
Signature

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Relationship to Patient
Date

MonthDayYear
Date
Name

First NameLast Name
AUTHORIZATION FOR CARE/ INFORMED CONSENT

I have been informed that all forms of health care, including chiropractic, have certain risks and possible side effects. I understand that if the Doctor does accept my case, it does not guarantee or imply a guarantee of being able to cure or prevent any condition, illness, or injury. I hereby authorize the Doctor(s) and staff of Be Rooted Chiropractic & Wellness to treat my child’s condition as deemed appropriate.
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FINANCIAL/ INSURANCE AGREEMENT

At Be Rooted Chiropractic & Wellness, we accept most insurance plans and offer cash payment options. We will happily check your benefits and directly bill the insurance company for services covered per your policy with the following understanding. I clearly understand insurance verification and authorization is not a guarantee of payment and that I am responsible for all services rendered including but not limited to deductibles, co-payments, non-covered or denied services rendered, vitamins, supplements, and durable goods. I authorize Be Rooted Chiropractic & Wellness to release my information to the insurance company to receive reimbursement for services provided. I authorize the use of this signature on all insurance reimbursements. If care is suspended or terminated for any reason, any outstanding balance will become immediately due and payable.
Who should receive bills for payment on your account
Signature*

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Date*

MonthDayYear
Date
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