Pediatric History Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of birth:

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Parent or legal guardian's name:

Delivery Method:

Any complication during pregnancy or delivery?

Please describe the complication:

Any known congenital anomalies / defects?

Please describe:

Current Weight:

Current Height / Length

Do you notice any developmental delays in your child?

Please Describe:

Pediatrician's name:

Clinic Name

Approximate date of last visit

Has your child had chiropractic care in the past?

Where did they receive chiropractic care?

Approximate date of last adjustment

Has your child ever been in an auto accident?

Please describe the accident and the approximate date:

Has your child ever had any other significant injuries, falls, head injuries, or accidents:

Please describe the injuries and approximate dates:

Has your child ever had any broken bones or dislocations?

Please describe:

Has your child ever been involved in, or is currently involved in high impact / contact sports (wrestling, football, soccer, martial arts, gymnastics)?

Please describe:

Has your child ever had a surgical procedure?

Please Describe the procedure(s) and approximate date(s):

Has your child ever been hospitalized?

Please describe the reason for any hospitalizations and approximate dates:

Please check all that apply:

Please list any supplements, OTC medications, prescription medications along with the reason for taking it:

Example: laxatives for contipation, vitamin C for immune support, etc

The reason why your child is here

Please describe any specific conditions and approximately how long they have been an issue:

Are any of the specific conditions due to an injury or specific incident or event?

Please describe:

How long has this been an issue with your child (approximately)?

How often does this concern bother your child?

Other

If "other", please describe:

Has you child seen other doctors for the same issue(s)?

Please describe the type of treatment that has already been undertaken:

Is the problem....

Is the problem interfering with...

Do any particular movements or activities aggravate the problem? If yes, please describe.

General:

Female reproductive system:

Eyes, Ears, Nose, Throat

Respiratory System

Nervous System

Emotional / Mental Health:

Musculoskeletal System:

Cardiovascular System:

Skin:

Urinary System:

Gastrointestinal System:

Illness / Disease in the past:

Please indicate any other problems you would like the doctor to address, or add any other information you think might be relevant to your child's health history.

Office Policy

Thank you for choosing Chiropractic Advantage for your health care needs. We are committed to providing you with exceptional care and service. To ensure we can serve you and all our patients effectively, we've outlined our office policies below.

Payment Policy

We operate on a simple, straightforward payment model. Payment is due in full at the time of service, which allows us to keep our fees competitive and focus on your care rather than insurance paperwork. We accept cash, checks, and credit/debit cards.
Please note that we do not accept payment on lien for personal injury or worker's compensation cases.

Health Insurance

Many health insurance policies now cover alternative health care. However, we've found that a significant number of plans have co-pays that exceed our fees. For this reason, we do not submit claims directly to insurance companies. You are welcome to file for reimbursement on your own, though we cannot guarantee what your insurance will cover.

Respecting Everyone's Time

Our goal is to provide quality, timely care to every patient. When you schedule an appointment, you're reserving dedicated time with our providers-time that becomes unavailable to other patients who may need care. We deeply appreciate your consideration in helping us serve everyone effectively.

Appointment Reminders and Confirmation

We'll send you text and email reminders about your upcoming appointments. To help us manage our schedule efficiently, we ask that you confirm your appointment through our text reminder system or by calling our office. Any unconfirmed appointments will be automatically released back into our schedule at 6 PM the day before, making that time available to other patients. Same-day appointments are automatically confirmed.

If You Need to Cancel or Reschedule

We understand that life happens! If you need to cancel or reschedule, we simply ask that you let us know by 5 PM on the day before your appointment. This advance notice allows us to offer your appointment time to another patient who may be waiting for care.

To cancel or reschedule:

Reply to your appointment confirmation text, or
Call our office during business hours:

Monday-Thursday: 8 AM-6 PM
Friday: 8 AM-12 PM

Late Cancellations and Missed Appointments

To help us maintain appointment availability for all patients, we have a $50 fee for cancellations made after 5 PM the day before your appointment, or for missed appointments without notification. For new patients, a late cancellation or no-show for your first appointment will result in the full new patient fee.

We truly appreciate your partnership in helping us provide excellent care to our entire patient community.

I have read and understand the office policies outlined above. The information I have provided is accurate to the best of my knowledge.

Print Name: Your print name

Signature

Pediatric History Form

Personal Information

Birth History

Vital Health Information

Past Health Information

Health Habits

Medications & Supplements

Current Health Status

Review of Health Systems (choose all that apply)