Pediatric History Form
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5PEDIATRIC 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
Patient Name: _____________________________________________ S.S.#: ________________________________
Address: ____________________________________________________ City: _________________________
State: ___________________ Zip ______________ Home Phone __________________________________
Birth Date: ______/_______/___________ Work Phone: _______________________________________
Sex:______ Weight:___________ Height: ___________ Referred By: _________________________________
Names of Parents/Guardians: _________________________________________________________________
Purpose For Contacting Us? ___________________________________________________
Other Doctors Seen for this Condition: _______N _______ Y, Doctors Names and Prior Treatments: _____
_________________________________________________________________________________
Other Health Problems? _______________________________________________________________________________
Check any of the Following Conditions Your Child has Suffered from During the Past Six Months:
□Ear Infections
□Scoliosis
□Seizures
□Chronic Colds
□Headaches
□Asthma/Allergies
□Digestive Problems
□ADHD
□Recurring Fevers
□Growing/Back Pains
□Colic
□Bed Wetting
□Car Accident
□Temper Tantrums
□Other _______________
Family History: ______________________________________________________________________________________
Previous Chiropractor: _________________________________________________________________________________
Date of Last Visit: ______/_____/_________ Reason: ________________________________________________________
Name of Pediatrician: _________________________________________________________________________________
Date of Last Visit: ______/_____/_________ Reason: ________________________________________________________
Are you satisfied with the care your child received there? __________N ________Y
Number of Doses of Antibiotics Your Child has Taken: During the Past Six Months ______
Total During Lifetime: ______
Number of Doses of Other Prescription Medications Your Child has Taken:
During the Past Six Months ______
Total During Lifetime: _________________________________________________
__________________________________________________________________________________________________
Vaccination History: ___________________________________________________________________________________
Prenatal History:
Name of Obstetrician/Midwife: __________________________________________________________________________
Complications during Pregnancy? ________N _______Y, List: ________________________________________________
Ultrasounds during Pregnancy? ________N _______Y, Number: ________
Medications during Pregnancy/Delivery _______N _______Y, List: _____________________________________________
Cigarette / Alcohol Use During Pregnancy: ________N ________Y
Location of Birth _________Hospital ________Birthing Center _________Home _______Other
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