Pediatric History Form Page 2
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6BIRTH HISTORY:
Was the delivery premature or full-term? Gestational Age: _________________________________________________
Was the delivery via C-Section or vaginal delivery?________________________________________________________
Was the delivery an emergency?______________________________________________________________________
Was medication given to induce labor?
Yes
No _____________________________________________________
Were any medications given during labor?
Yes
No __________________________________________________
Were forceps used in the delivery?
Yes
No
Vacuum Extraction?
Yes
No
Any complications during the delivery?
Yes
No ______________________________________________________
Birth Weight:
Length: _____________
APGAR scores: at one minute_______________, at five minutes_________________
Was the use of oxygen required?
Yes
No
Did your child require additional hospitalization?
Yes
No _______________________________________________
Was your child bottle, breast-fed or both?________________________________________________________________
Did your child have difficulty latching on or any sucking difficulties?
Yes
No _______________________________
DEVELOPMENTAL HISTORY: (Physical, Speech, Emotional, Social, Academic)
Please tell us about your child’s development. Did he/she show signs of delay or advancement? ___________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Age when he/she rolled over:______________________
spoke his/her first word:_____________
sat up unsupported:________________
spoke in sentences:_______________
crawled:_________________________
became toilet trained:_____________
walked:__________________________
Does he/she show any signs of food allergies/intolerances?
Yes
No _____________________________________
Is / has your child been involved in any high impact or contact type sports ( i.e., Soccer, Football, Gymnastics, Baseball,
Cheerleading, Martial Arts, Wrestling, etc. ) ?
Yes
No
List: __________________________________________
________________________________________________________________________________________________
Has Your Child Ever Been Involved in a Car Accident ?
Yes
No ________________________________________
Has Your Child Been Seen on an Emergency Basis?
Yes
No, List: ____________________________________
Other Traumas Not Described Above ?
Yes
No, List: ________________________________________________
Does your child tend to fall frequently?
Yes
No
Does your child show any signs of muscle weakness?
Yes
No
Thank you for taking the time to complete this form. This information is valuable in obtaining an overall view of your child,
as certain conditions or procedures may impact the spine and nervous system. Any additional information you’d like to
share in order to help us learn more about your child is absolutely welcomed! __________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
WE ARE HERE TO SERVE YOU AND YOUR CHILD, AND ENCOURAGE YOU TO ASK QUESTIONS.
YOUR INPUT AND PARTICIPATION IS VITAL AND WILL HELP DETERMINE YOUR CHILD’S RESULTS.
AUTHORIZATION FOR CARE OF MINOR
I hereby authorize this office and its doctors to administer care to my Son / Daughter as deemed necessary. I clearly
understand and agree that I am personally responsible for payment of all fees charged by this office.
Signed: ___________________________________ Witnessed: ________________________________Date: _______
Name of Insurance Company: _____________________________________ Policy #: ___________________________
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