PEDIATRIC FORM
Child's Information
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Gender
*
Male
Female
Height
*
Weight
*
Guardian(s) Information
Name(s)
*
Relationship(s)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Who may we thank for referring you?
*
Health Concerns
List the Health Concerns That Brought You into This Office
*
Health Concerns
(List according to severity)
Rate of Severity
0=painless
10=unbearable
Primary
1
2
3
4
5
6
7
8
9
10
Second
1
2
3
4
5
6
7
8
9
10
Third
1
2
3
4
5
6
7
8
9
10
Fourth
1
2
3
4
5
6
7
8
9
10
Timeline
*
When did this problem start?
Have they had the problem before?
If so, when?
Primary
Second
Third
Fourth
Source and Frequency
*
Did the problem begin
with an injury?
Are the symptoms
Constant (C)
or Intermittent (I)
Primary
C
I
C
I
Second
C
I
C
I
Third
C
I
C
I
Fourth
C
I
C
I
Other Health Concerns
Have they ever seen other doctors for these conditions?
*
Yes
No
If Yes:
Chiropractor
Medical Doctor
Other
Who?
When?
Results?
Pregnancy Information
How was your pregnancy?
Any pregnancy complications?
Did you take any medication during your pregnancy?
Other Information
Delivery Information
Location of Birth
Hospital Birth Center
Home
Other
Birth Intervention
Forceps
Vacuum Extraction
Caesarian Section
Other
Induced Birth?
Yes
No
If so, explain:
Medications during delivery?
Other Information
Post-Birth Information
Birth Weight
Birth Length
Breast Fed?
Yes
No
If so, how long?
Formula Fed?
Yes
No
If so, how long?
Introduced solid foods at
blanks
months old.
Food Allergies or Intolerances
Drugs and Trauma History
Doses of Antibiotics/Prescription Drugs Taken by Child
Presently Taking:
Past 6 Months:
Total Lifetime:
OTC Drugs Taken by Child (Tylenol, cough syrup, laxatives, etc...)
Presently Taking:
Past 6 Months:
Total Lifetime:
List any/all surgical operations and years:
List any other injuries to the spine, minor or major, that the doctor should know about:
Has your child ever been knocked unconscious?
Yes
No
Fractured a bone?
Yes
No
If yes to either of the above, please describe:
Other Trauma
Quadruple Visual Analogue Scale
On a scale of 1-10, 10 being the worst, respond to each of the following:
Please give your best answer to these questions on your child's behalf.
How much pain do they appear to be experiencing RIGHT NOW?
*
No Pain
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is No Pain, 10 is Unbearable
What is their typical or AVERAGE pain?
*
No Pain
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is No Pain, 10 is Unbearable
What is their pain level at its BEST? (Do they ever seem to not be experiencing any pain? How close to 0?)
No Pain
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is No Pain, 10 is Unbearable
What is their pain level at its WORST? (How close does their pain get to 10 at its worst?)
*
No Pain
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is No Pain, 10 is Unbearable
Activities of Life
Please identify your child's ability to perform these tasks
Can Do
Limited
Unable to
Perform
Holding Head Up
Tummy Time
Nursing
Sitting Up
Crawling
Standing Alone
Walking Alone
Other Activities
Activity
Limited
Unable to
Perform
Other
Other
Other
Submit
Should be Empty: