Reignite Chiro - NP Pediatric Packet

New Patient Pediatric Paperwork
Personal Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
MaleFemale
Occupation
MarriedWidowedDivorced
Who can we thank for referring you to our office
Email
example@example.com
Work Email
example@example.com
Other family member's names
Page 1 of 7

Insurance Information

(Please give your insurance card and driver's license to the front desk)
Primary Insurance Carrier
Subscriber's Name
Occupation
Employer
Subscribers Address
Subscribers Phone
Format: (000) 000-0000.
Subscribers Date of Birth

MonthDayYear
Date
Policy Number
Group No
In Case of Emergency
Emergency Name
Phone No
Format: (000) 000-0000.
Relationship
Page 2 of 7

Feeding History
YesNo
How long
YesNo
How long
YesNo
Type

If yes, please list:

Rows	Allergies
1
2
3

Page 4 of 7

Developmental History

Your child’s spine is most vulnerable to stress and should routinely be checked by a doctor ofchiropractic for prevention and early detection of vertebral subluxation (spinal nerveinterference). At what age was your child able to:

Rows	Age
Respond to stimuli
Respond to visual stimuli
Sit up
Cross Crawl
Hold head up
Stand alone
Walk alone

YesNo

List Sports

Rows	Sports
1
2
3

Other traumas or surgeries not described above?
Page 5 of 7

Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Parent Guardian Name

First NameLast Name
With our office policy, a credit card is required to have on file for missed appointments. Please fill out the information below.
Card Number
Expiration Date

MonthDayYear
Date
CVV Code
By signing this agreement, I'm acknowledging that my card may be charged for any future visits that I have scheduled but do not show up for. These visits include my child's new patient appointment, chiropractic adjustments or reassessments. The fee for missed appointments are: New Patient Appointment $95, Adjustments & Reassessments $45.
Signature

Clear
Date

MonthDayYear
Date
Page 7 of 7
Should be Empty:

Rows	Reason for Doctor's Visit	Prior Treatment	Doctor
1
2
3

Rows	Drugs/Medications:	Dosage:	Frequency:	Reason for use:
1
2
3

Rows	Drugs/Medications:	Dosage:	Frequency:	Reason for use:
1
2
3

Rows	Patient	Sibling	Mother	Father
Acid Reflux
ADHD
Allergies
Anxiety
Arthritis
Asthma
Autoimmune problems
Bed Wetting
Cancer
Constipation
Depression
Diabetes
Dizziness/Vertigo
Ear Infections
Eczema
Fatigue
Flu
Headaches/Migraines
Heart problems
Immune problems
Infertility
Kidney problems
Liver problems
Menstrual problems
Nausea
Numbness
Sciatica
Scoliosis
Seizures
Sinus problems
Stiffness
Stomach trouble/ Indigestion
TMJ pain
Ulcers

New Patient Pediatric Paperwork

Personal Information

Insurance Information

In Case of Emergency

Pediatric History Form

Primary Health Concern

Has the infant/child had previous chiropractic care?

Feeding History

Developmental History

Lifestyle