Pediatric History Form

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Upper Valley Chiropractic
“A Family Health and Wellness Center”
PEDIATRIC HISTORY FORM
Dear New Patient,
It is a pleasure to welcome you to our family of happy and healthy chiropractic patients. Please let us know if
there is any way we can make you and your family feel more comfortable. To help us serve you better, please
complete the following information. We look forward to working with you to build better health for your family.
Date:_________
Patient Name: ____________________________________________ S.S. #:_________-________-___________
Address:_____________________________________________
City:________________________________
State:_________ Zip:____________
Age:_______ Birth Date: _____/______ /________
Sex:_____ Weight:__________ Height: ____________
Names of Parents / Guardians: __________________________________________________________________
Home Phone:____________________ Work Phone:____________________ Cell Phone:___________________
Referred By:________________________________
Purpose For Contacting Us?
_________________________________________________________________
________________________________________________________________________________________________
Referring Physician’s Name and Address:_____________________________________________________________
________________________________________________________________________________________________
What are the goals that you hope your child will gain?_______________________________________
________________________________________________________________________________________________
MEDICAL HISTORY:
Check the following conditions that your child has suffered from: (Please elaborate on all marked boxes as appropriate in
the space provided)
ADD/ADHD
Constipation
Fatigue
Orthopedic Conditions
Allergies
Diabetes
Headaches
Scoliosis
Asthma
Digestive Problems
Hearing Difficulties
Seizures
Blood Disorder
Depression/ Anxiety
Heart Problems
Sleep Disturbances
Chronic Colds
Dyslexia
Kidney Disorders
Torticollis
Colic
Ear Infections
Lymph Disorders
Vision Difficulties
Autism
Sensory Processing Challenges
Other____________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Current Medications:________________________________________________________________________________
Y
Has your child ever had surgery?
No
es__________________________________________________________
Did you CHOOSE to have your child vaccinated?
No
Yes_____________________________________________
Has your child had a lot of dental work?
No
Yes If so, what and when?___________________________________
Does your child wear any orthodontic devices?
No
Yes _______________________________________________
PRENATAL HISTORY:
Were there any complications or unusual stressors during the pregnancy?
Yes
No _________________________
________________________________________________________________________________________________
Medications during pregnancy?
Yes
NO ___________________________________________________________
Cigarette/ Alcohol use during pregnancy?
Yes
No ___________________________________________________

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