Patient Refusal Information Sheet
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8Pediatric Intake Form
Ages 0-12
Date:_________________________
Name______________________________________________________________ Nickname_____________________________________________
Date of Birth__________________________________________ Age__________ Referred By_______________________________________
Name of Parents___________________________________________________________________________________________________________
Address____________________________________________________________________________________________________________________
City_________________________________________________
State__________________ Zip Code___________________________________
Home Phone_______________________________________
Cell Phone_________________________________________________________
Please check the purpose for your child’s visit:
early detection
crisis management
prevention
wellness
maximizing normal growth and development
Please answer the following questions to the best of your ability. If the question does not apply, please write
NA.
Has your child been checked by a Doctor of Chiropractic?
Yes
No
Name of Chiropractor/last seen?________________________________________________________________________________
Who is your regular Pediatrician?_______________________________________________________________________________________
PRESENT HEALTH CONCERNS:
Primary reason you are here_____________________________________________________________________________________________
Pain or Problem started on________________________________________________________________________
Pains are:
dull
sharp
throbbing
Burning
deep
aching
tingling
Stabbing
cramping
numbness
radiating
stiffness
Frequency (% of the day):
0-25%
25-50%
50-75%
75-100%
Other__________________________
Does this pain shoot, radiate, or travel in your body? If yes, where?____________________________________
Since it began, is it:
Same
Better
Worse
Worse in AM
Worse in PM
Same All Day
What makes this WORSE?
sitting
standing
walking
bending
stooping
lifting
sleeping
sneezing
coughing
straining
reaching
twisting
looking up
looking down
movement
Rest
lying supine
driving
typing
scooping
house chores
exercise
lying prone
stairs
What makes this BETTER?
sitting
standing
lying
knees bent up
support
no movement
movement
heat
ice
topical analgesic
ibuprofen
medication
rest
stretching/exercise
Is this problem interfering with your child’s sleep?
Yes
No Eating?
yes
No Daily Routine?
Y
N
Check any of the following conditions your child has had or is suffering from:
Colic
Ear Infections
Sleep Problems
Night Terrors
Learning Difficulties
Allergies
Asthma
Headaches
Constipation/Diarrhea
Emotional Disorder
Tantrums
ADD/ADHD
Muscle Cramps
Infections/Colds
Upper/Midback Pain
Dizziness
Fatigue
Depression
Sore Throats
Bloating/Gas
Dr. Heather Hunscher, DC * 105 Franklin St, Unit 11 * Westerly, RI * 02891 * 401-757-0408
Rev 3/15
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