trumotion.org - Pediatric Patient Questionnaire Form

Pediatric Patient Questionnaire
Confidential Patient Information
Name

First NameLast Name
Parents/Guardian Name(s)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile phone number
Please enter a valid phone number.Format: (000) 000-0000.
Other phone number
Please enter a valid phone number.Format: (000) 000-0000.
Child's sex
Email
example@example.com
Child SSN
Date of birth

MonthDayYear
Date
Age
Height
Weight
How did you hear about us?
Who is your primary physician?
Is your child receiving care from any other health professionals?

YesNo
If yes, please name them and their specialty
Please list any drugs/ medications/vitamins/ herbs or 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 begin?
How did the problem start?

SuddenlyGraduallyPost-injury
Has your child ever received care for this condition?

YesNo
If yes, please explain
In this condition

Getting worse ImprovingIntermittentConstantUnsure
What makes the problem better?
What make the problem worse?
Health Goals for Your Child
What are your top three goals for your child?
What would you like to gain?

Resolve existing conditionOverall wellnessBoth
Has your child ever visited a chiropractor?

YesNo
If yes, what is their name
What is their specialty?

Pain ReliefPhysical Therapy & RehabNutritionSubluxation-basedOther
Pregnancy & Fertility History

Please tell us about your pregnancy
Any fertility issues?

YesNo
If yes, please explain
Did mother smoke?

YesNo
If yes, how often
Did mother drink?

YesNo
If yes, how often
Did mother exercise?

YesNo
If yes, please explain
Was mother ill?

YesNo
If yes, please explain
Any utralsounds?

YesNo
If yes, please explain
Please explain any noticable espisodes of mental or physicals stress during your pregnancy
Please explain any other concerns or notable remarks about your child's conception or pregnancy
Labor & Delivery History
Child's birth was:

Natural vaginal birthScheduled C-sectionEmergency C-section
At how many weeks was your child born?
Where was your child born?
Who delivered your baby?
Please indicate any applicable interventions or complications

BreechInductionPain medsEpiduralEspisiotomyVacuum extractionForcepsOther
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 min
Grow & Development History
Is/was your child breastfed?

YesNo
If yes, how long
Difficulty with breastfeeding?

YesNo
Did they ever use formula?

YesNo
If yes, at what age?
If yes, what type?
Did/does your child suffer from colic, reflux, or constipation as an infant?

YesNo
If yes, please explain
Did/does your child frequently arch their neck/back, feel stiff, or bag their head?

YesNo
At what age did the child:
Respond to sound
Follow an object
Hold their head up
Vocalize
Teethe
Sit alone
Sit alone
Crawl
Walk
Begin cow's milk
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 vaccine your child?

NoYes, on a delayed or selective scheduleYes, on schedule
If yes, please list any vaccine reactions
Has your child received any antibiotics?

YesNo
If yes, how many times and list reason
Night terrors or difficulty sleeping

YesNo
If yes, please explain
Behavioral, social or emotional issues?

YesNo
If yes, please explain
How many hours per day does your child typically spend watching TV, computer, tablet or phone?
How would you describe your child's diet?

Mostly whole, organic foodsPretty averageHigh amount of processed foods
Acknowledgement & Consent
Patient/Guardian Signature
Date

MonthDayYear
Date
Patient Review of Systems
Please check the corresponding boxes for each symptom or condition you have experienced - including both past and present.

REGION: Cervical

FUNCTIONS:
- Autonomic Nervous System
- ENT System
- Vision, Balance & Coordination
- Speech
- Immune System
- Digestive System
- Nerve Supply to Shoulders, Arms & Hands
- Sympathetic Nucleus
- Metabolism
Please select the symptoms you experienced

Colic & Excessive CryingEar & Sinus InfectionsAllergies & CongestionImmune DeficiencyVertigo & DizzinessSore Throat & StrepSwollen Tonsils & AdenoidsVison & Hearing IssuesLow Energy & FatigueDifficulty SleepingPain, Numbness & Tingling in Arms to HandsEpilepsy & SeizuresSensory & SpectrumFocus & Memory IssuesAnxiety & StressBalance & CoordinationSpeech IssuesTMJ/Jaw PainStiff Neck & ShouldersDepressionHigh Blood PressurePoor Metabolism & Weight ControlHeadache & MigrainesADD / ADHD
Please select the symptoms that you are experiencing

Colic & Excessive CryingEar & Sinus InfectionsAllergies & CongestionImmune DeficiencyVertigo & DizzinessSore Throat & StrepSwollen Tonsils & AdenoidsVison & Hearing IssuesLow Energy & FatigueDifficulty SleepingPain, Numbness & Tingling in Arms to HandsEpilepsy & SeizuresSensory & SpectrumFocus & Memory IssuesAnxiety & StressBalance & CoordinationSpeech IssuesTMJ/Jaw PainStiff Neck & ShouldersDepressionHigh Blood PressurePoor Metabolism & Weight ControlHeadache & MigrainesADD / ADHD
REGION: Upper Thoracic

FUNCTIONS:
- Upper G.I
- Respiratory System
- Cardiac Function
Please select the symptoms that you experienced.

Reflux / GERDChronic Colds & CoughAsthmaBronchitis & PneumoniaFunctional Heart Conditions
Please select the symptoms that you are experiencing.

Reflux / GERDChronic Colds & CoughAsthmaBronchitis & PneumoniaFunctional Heart Conditions
REGION: MID THORACI

Functions:
- Major Digestive Center
- Detox & Immuniny
Please select the symptoms that you experienced.

Gallbladder Pain / IssuesJaundiceFeverIndigestion & HeartburnStomach Pains & UlcersBlood Sugar Problems
Please select the symptoms that you are experiencing.

Gallbladder Pain / IssuesJaundiceFeverIndigestion & HeartburnStomach Pains & UlcersBlood Sugar Problems
REGION: LOWER THORACIC

Functions:
- Stress Response
- Filtration & Elimination
- Gut & Digestion
- Hormonal Control
Please select the symptoms that you experienced.

Behavior IssuesHyperactivityChronic Fatigue Chronic StressAllergies & EczemaSkin Conditions/RashKidney ProblemsGas Pain & Bloating
Please select the symptoms that you are experiencing.

Behavior IssuesHyperactivityChronic Fatigue Chronic StressAllergies & EczemaSkin Conditions/RashKidney ProblemsGas Pain & Bloating
REGION: Lumbar, Sacrum & Pelvis

FUNCTIONS:
- Lower G.I (Absorption & Motility)
- Gut-Immune System
- Major Hormonal Control
Please select the symptoms that you experienced.

ConstipationChrohn's, Colitis & IBSDiarrheaBed-wettingBladder & Urination IssuesCramps & Menstrual IssuesCysts & EndometriosisInfertilityImportencyHermorrhoidsSciatica & Radiating PainLumbopelvic / ST Joint PainHamstring TightnessDisc DegenerationLeg Weakness & CrampsPoor Circulation & Cold FeetKnee, Ankle & Foot PainWeek Anke & ArchesLower Back PainGlutein & Casein Intolerance
Please select the symptoms that you are experiencing.

ConstipationChrohn's, Colitis & IBSDiarrheaBed-wettingBladder & Urination IssuesCramps & Menstrual IssuesCysts & EndometriosisInfertilityImportencyHermorrhoidsSciatica & Radiating PainLumbopelvic / ST Joint PainHamstring TightnessDisc DegenerationLeg Weakness & CrampsPoor Circulation & Cold FeetKnee, Ankle & Foot PainWeek Anke & ArchesLower Back PainGlutein & Casein Intolerance
Please review to ensure the details are correct before completion.
Should be Empty:

Pediatric Patient Questionnaire

Confidential Patient Information

Current Health Conditions

Health Goals for Your Child

Pregnancy & Fertility History

Labor & Delivery History

Grow & Development History

At what age did the child:

Acknowledgement & Consent

Patient Review of Systems