Pediatric Health History Form
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1
2Pediatric Health History
Child’s Full Name___________________________________________________ Today’s Date_____________________
Address_____________________________________________City___________________State_____Zip____________
Birthdate________________Age______Parent’s Names____________________________________________________
Mother’s Home Phone____________________Cell ______________________ Email_____________________________
Father’s Home Phone ____________________Cell ______________________ Email_____________________________
Has any family member been a patient here? Yes No Names__________________________________________
Has this patient had any previous chiropractic care? Yes No Dr._________________ Date:__________________
Primary Care Physician_________________________ Last Visit_____________ Reason__________________________
Reason For Visit
Please describe your child’s major complaint:
__________________________________________________________________________________________________
Date Started___/___/___ Had before? Yes No Explain:______________________________________________
Secondary complaint_________________________________________________________________________________
Date Started___/___/___ Had before? Yes No Explain:______________________________________________
Are any conditions interfering with: Sleep School Daily Routine Sports Other _______________________________
Birth History
Vaginal
C-Section
Forceps
Vacuum
Delivery Method (check all that apply):
Epidural
Induced
Breech
Back Birth
Location of Birth: Hospital Birthing Center Other _______________________________
Yes No
Chiropractic care during the pregnancy?
Details________________________________________
Yes No
Any complications during pregnancy?
Details________________________________________
Yes No
Medications/Drugs during?
List___________________________________________
Yes No
Cigarette/Alcohol use during?
Explain________________________________________
Yes No
Any known congenital anomalies or defects?
Explain________________________________________
Health History
Yes No
Breast fed?
How Long?___________________________________
Yes No
Formula fed?
How Long?________Brand______________________
Yes No
Milk in a bottle?
How Long?________Kind of milk_________________
Yes No
Food or other allergies?
List_________________________________________
Yes No
Has your child ever taken antibiotics?
Explain______________________________________
Yes No
Any prescription medication?
Explain______________________________________
Yes No
Any vitamins or supplements?
Explain______________________________________
Yes No
Has your child ever had surgery?
Explain______________________________________
Yes No
Emergency Room visits?
Explain______________________________________
Yes No
Vaccinations up-to-date?
Explain______________________________________
Age Development: Rolled over_________ Sat Up_________ Crawled_________ Walked________ Talked__________
Have you ever been concerned your child was not developing and achieving normal milestones? Yes No
Explain____________________________________________________________________________________________
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