New Pediatric Patient Paperwork

New Pediatric Patient Paperwork

Complete this pediatric health history form for your child, including contact details, current conditions, and chiropractic care history.
Pediatric Health History
Child’s Name

First NameLast Name
Parents’ Names
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone(s)
Please enter a valid phone number.Format: (000) 000-0000.
Email(s)
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Sex
Height (ft and in.)
Weight
Primary Care Physician?
How did you first hear about us?
Referral source (old field, hidden 2026-10-16)
Who can we thank? (name)
Is your child receiving care from any other health professionals?
If yes, please name them & their specialty:
Please list any drugs/medications/vitamins/herbs/others 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?
Has your child received care for this condition before?
If yes, please explain:
Is this condition:
What makes the problem better?
What makes it worse?
Health Goals for Your Child
What are your top three health goals for your child:
1.
2.
3.
Have you ever visited a chiropractor?
If yes, what is their name?
What is their specialty?

Other
Pregnancy & Fertility History
Please tell us about your pregnancy
Any fertility issues?
If yes, please explain:
Did mother smoke?
If yes, how many per week?
Did mother drink?
If yes, how many per week?
Did mother exercise?
If yes, please explain:
Was mother ill?
If yes, please explain:
Any ultrasounds?
If yes, please explain:
Please explain any notable episodes of mental or physical stress during pregnancy?
Please explain any other concerns or notable remarks about your child's conception or pregnancy?
Labor & Delivery History
Child's birth was:
At how many weeks was your child born?
Doctor/OB/Midwife's Name:
Child's birth was:

Other
Please check any applicable interventions or complications:

Other
Please describe any other concerns or notable remarks about your child's labor and/or delivery:
Child's birth weight (lbs and oz):
Child's birth height (in.):
APGAR score at birth:
APGAR after 5 mins:
Growth & Development History
Is/was your child breastfed?
If yes, how long?
Difficulty breastfeeding?
Did they ever use formula?
If yes, what age?
If yes, what type?
Did/does your child ever suffer from colic, reflux, or constipation as an infant?
If yes, please explain:
At what age did the child:
Respond to sound
Follow an object
Hold their head up
Vocalize
Teethe
Sit alone
Crawl
Walk
Begin cow's milk?
Begin solid foods
Please list any food intolerances 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 vaccinate your child?
If yes, please list any vaccination reactions:
Has your child received any antibiotics?
If yes, how many times and list the reason:
Night terrors or difficulty sleeping?
If yes, please explain:
Behavioral, social, or emotional issues?
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?
Family Health History

Please mark any of the below conditions that you or your family have or have had in the past: write "C" if current issue or "P" if past issue

Rows	Yourself	Spouse	Children	Mother	Father
Acid Reflux
Addiction
ADHD
Allergies
Anxiety/Nervousness
Arthritis
Asthma
Autism Spect. Disorder
Autoimmune Disorder
Bladder Problems
Chronic Fatigue
Depression
Disc Problems
Dizziness
Ear Infections
Epilepsy
Fainting/syncope
Fibromyalgia
Headaches
Heart Disorders
High Blood Pressure
Infertility
Irritable Bowel Synd.
Kidney Condition
Lupus
Menstrual Problems
Migraines
Multiple Sclerosis
Nausea
Numbness/tingling
Sciatica
Sinus problems
Stiffness
Stomach Conditions
Throat Issues
Thyroid Problems
TMJ Disorder
Ulcers
Vertigo

Other comments
Assignment of Benefits
I hereby authorize payment to be made directly to Absolute Chiropractic, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Absolute Chiropractic for any and all services I receive at this office. In the event this account is referred to a collection agency, I understand and agree to pay any collection fees incurred by Absolute Chiropractic in addition but not limited to any attorneys' fees or costs of collection.
Parent/Guardian Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Informed Consent
We encourage and support a shared decision making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgably give or withhold your consent. Chiropractic care concerns itself with the detection, analysis, and correction of vertebral subluxation, or malposition of the spinal vertebrae impacting nervous system function. It centrally involves what is known as a chiropractic adjustment, involving the use of hands or instruments with a precise direction and force to reposition anatomical structures. Potential benefits include restoring normal joint motion, reducing swelling in a joint, reducing pain in the joint, improved neurological function and overall well-being. We will conduct diagnostic or examination procedures, which, while non-invasive, may be uncomfortable in some cases. In addition to the benefits of chiropractic care and treatment, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them. Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, and fracture. In addition, there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence do not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment. I have been informed of the nature and purpose of chiropractic care, the possible consequences of care and the risks of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risks, consequences, and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of care and the treatment. I have read the above content and understand the information provided. All questions I have about this information have been answered to my satisfaction. Having this knowledge, I intend this consent to cover the entire course of care from all providers in this office.
Patient Name
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If the patient is a minor: In addition, by signing below, I give permission for the above-named minor patient to be managed by the doctor even when I am not present to observe such care.
Parent/Guardian Name
Relationship to patient
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
X-Ray Authorization
As your healthcare provider, we are legally responsible for your chiropractic records. We must maintain a record of your x-rays in our files. At your request, we will provide you with a copy of your x-rays in our files. Digital copies of your x-rays are available within 5 business days of your request, at no charge. Please note: X-rays are utilized in this office to help locate and analyze VERTEBRAL SUBLUXATIONS. However, if any abnormalities are found, we will bring it to your attention so that you can seek proper medical advice. BY SIGNING BELOW, YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS:
Print your name here
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Patient's age
FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE,
Please call us at (732) 756-1159 before your visit. If you are or may be pregnant, you will fill out our prenatal paperwork instead, and we will talk with you about x-rays.
Patient or Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Notice of Privacy Practice Acknowledgement
I understand that I have certain rights of privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: 1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and/or indirectly. 2. Obtain payment from third-party payers. 3. Conduct normal healthcare operations, such as quality assessments and physicians' certifications. I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I also understand that I may request, in writing, that you restrict how my information is used to disclose or carry out treatment, payment, or healthcare operation. I understand that you are not required to agree to my requested restrictions, but if you agree, then you are bound to abide by such restrictions.
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

New Pediatric Patient Paperwork

Pediatric Health History

Current Health Conditions

Health Goals for Your Child

Pregnancy & Fertility History

Labor & Delivery History

Growth & Development History

Family Health History

Assignment of Benefits

Informed Consent

X-Ray Authorization

Notice of Privacy Practice Acknowledgement