Pediatric New Patient Intake
Confidential Patient Information
Child's Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Age
Child's Sex
Female
Male
Secondary Parent/Guardian Name
First Name
Last Name
Parent / Guardian Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
How did you hear about Radiant Life / who referred you?
Who referred you to our office
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Height
Child's Weight
Primary Care Physician
Name of PCP
Is your child receiving care from any other health care professionals?
Yes
No
If yes, who?
Name/s of other providers
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Health Goals for your Child
What motivated you to schedule this appointment today?
How long has your child's struggle been an issue?
Please Select
1-6 months
6-12 months
>1 year
Lifelong
How has their struggle affected home life
Strained family relationships
Disrupted Routines
Weariness for caregivers
Increased confrontation with emotional outbursts
Other
How has their struggle affected social life?
Conflict with peers
Social rejection
Isolation / withdrawl
Lack of enjoyment in social situations
Bullying
Other
How has their struggle affected school life?
Trouble following directions
Conflicts with teachers or classmates
Late homework
Challenges with transitions
Sensory Sensitivities
Other
What does a bad day look like for your child?
Over the next year, what positive changes or improvements do you hope to see for your child regarding their current challenges?
What do you think might happen if this positive change does not occur in your child’s life?
What specific routines, environmental changes, or parenting strategies are you using right now to help your child with their challenges?
If we’re able to help you find solutions for your child’s challenges, what would that mean for you and your family?
What are your top 3 health goals for your child?
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Current Health Conditions
Have you ever visited a chiropractor?
Yes
No
What is their specialty?
Pain Relief
Physical Therapy
Subluxation-based
Nutritional
Other
List any health condition/s your child has 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
Is this condition?
Getting worse
Improving
Intermittent
Constant
Unsure
What makes the problem worse?
What makes the problem better?
What would you like gain from receiving chiropractic care?
Resolve existing condition
Overall Wellness
Both
List out all current medication
Behavioral / Social Symptoms: (check all that apply)
Acting without thinking
Difficulty taking turns
Interrupting others
Withdrawn/social isolation
Relationship difficulties
Poor impulse control
Excessive movement
Fidgeting / restlessness
Talking excessively
Poor eye contact
Repetive movements
Self-harm
Learning disability or speech delay in a child
Other
Sensory and Motor Symptoms : (check all that apply)
Constantly bumping into things (clumsiness)
Trouble using fine motor skills
Feeling discomfort in certain types of clothing and fabric
Gagging when eating certain food textures
Needing to constantly touch things
Not recognizing personal space
Reacting to sudden movements, touches, loud noises and/or bright lights
Other
Mood / Emotional Symptoms: (check all that apply)
Difficulty managing emotions
Intense reactions/frustration
Mood swings / depressed mood
Loss of interest/pleasure
Irritability/outbursts of anger
Crying spells
Touchy/easily annoyed
Difficulty recognizing emotions
Low self-esteem
Feelings of rejection
Other
Cognitive Symptoms: (check all that apply)
Difficulty concentrating
Distractibility
Forgetful
Trouble organizing Tasks
Difficulty following directions
Intense interest in a limited number of things or trouble paying attention
Other
Physical / Somatic Symptoms: (check all that apply)
Weight gain/loss
Sleep disturbances
Chronic pain
Poor immune system
Digestion issues
Bedwetting
Other
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Pregnancy and Fertility History
Rows
Yes
No
If yes, please explain
Any Fertility Issues?
Did the mother exercise?
Was the mother ill?
Any ultrasounds?
Rows
Yes
No
If yes, how many per week?
Did the mother smoke
Did the mother drink?
Please explain any notable episodes of mental or physical stress during your pregnancy.
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Labor and Delivery History
Child's birth was
Natural Vaginal Birth
Scheduled C-section
Emergency C-section
At how many weeks was your child born?
Child's birth was at:
At home
At a Hospital
At a Birthing Center
Other
Doctor/Obstetrician's Name
Please check any applicable interventions or complications:
Breech
Forceps
Epidural
Episiotomy
Pain Meds
Inductions
Vacuum Extractions
Other
Please describe any other concerns or notable remarks about your child's labor and/ or delivery.
Child's Birth Height
Child's Birth Weight
Apgar Score at Birth
Apgar Score After 5 Minutes
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Growth and Development History
Is/was your child breastfed?
Yes
No
Difficulty with breastfeeding?
Yes
No
Did your child use formula?
Yes
No
Did/ does your child ever suffer from colic, reflux, or constipation as an infant?
Yes
No
Did/ does your child frequently arch their neck/ back, feel stiff, or bang their head?
Yes
No
At what age did the child:
Rows
Age
Respond to sound
Follow an object
Hold their head up
Vocalize
Begin Teething
At what age did the child:
Rows
Age
Sit alone
Crawl
Walk
Begin cow's milk
Begin solid food
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 life, including the year
Have you chosen to vaccinate your child?
Yes
No
Yes, on a delayed or selective schedule
Has your child received antibiotics?
Yes
No
Night terrors or difficulty sleeping?
Yes
No
How many hours per day does your child typically spend watching a TV, computer, tablet or phone?
How would you describe your child's diet?
Mostly whole, organic foods
Pretty average
High amount of processed foods
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Acknowledgement & Consent
HIPAA, Third-Party Storage, Consent to Treat, Release of Liability, Consent for Care Coordination, Consent to SMS/Email Marketing
I, the undersigned, am the parent or legal guardian of
Child's Name
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
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Submit
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