• Bayside Chiropractic Pediatric Patient Information Sheet

    This information is confidential
  • Date*
     - -
  •  -
  •  -
  • Birth Date*
     - -
  • Are You Employed?*
  •  -
  •  -
  • Last Physical Exam*
     - -
  •  -
  • Has child been treated for any health conditions last year?*
  • Has This Child Been to a Chiropractor Before?*
  • Is child's pain due to an automobile accident?*
  • Accident date occurred?*
     - -
  •  -
  • Are You Insured?*
  •  -

  • Patient History

  • Family History*
    Rows
  • Was This Pregnancy Typical, Full Term, 9 Months?*
  • Did Mother Have Any Illness During Pregnancy?*
  • Did Baby Have Any Problems During First Week of Life?*
  • Any Medication Taken During Pregnancy?*
  • Drug or Alcohol Use During Pregnancy?*
  • As Far As You Know, Is This Child's Development Typical?*
  • Please Check All Immunizations Received*

  • Any Feeding Issues?*
  • Describe Your Child's Health*
  • Describe Your Child's Behavior*
  • Please Check All That This Child Has Experienced*
  • Is This Child Taking Any Medications?*
  • Is This Child Taking Any Supplements or Vitamins?*
  • Does This Child Have Any Special Diet or Food Sensitivities?*

  • I hereby grant consent for Chiropractic treatment by Paul J. O'Brien, Jr, DC for the above named child. I have authority to grant consent for treatment.

  • Date of Signature*
     - -

  • Thank you for filling out our patient form! We recommend hitting the print button before submitting electronically so you have a backup copy. It will allow you to save as a PDF.

  •  
  • Should be Empty: