Pediatric History Form Page 2
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5Birth Intervention: ________ Forceps _________Vacuum Extraction ________ C-Section (Emergency or Planned?)
Complications During Delivery? _______N _______Y, List: ___________________________________________________
Genetic Disorders or Disabilities? _______N _______Y, List: __________________________________________________
Birth Weight: _______ Birth Length: _______ APGAR Scores: _______, ________
Feeding History:
Breast Fed ______N ______Y,
How Long: ________________________
Formula Fed ______N ______Y, How Long: _______________________ Type: __________________________________
Introduced to solids at: ________ Months, Cow's Milk at: ________ Months
Food / Juice allergies or intolerances: ________N _________Y, List: ___________________________________________
__________________________________________________________________________________________________
Developmental History:
During the following times your child's spine is most vulnerable to stress and should routinely be checked by a doctor of
chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference). At what age was your
child able to:
_______ Respond to Sound
_______ Cross Crawl
_______ Respond to Visual Stimuli
_______ Stand Alone
_______ Hold Head Up
_______ Walk Alone
_______ Sit up
According to the National Safety Council, approximately 50% of children fall head first from a high place during their first year
of life (i.e. a bed, changing table, down stairs, etc.). Was this the case with your child? ______N ______Y
Has your child been involved in any high impact or contact type sports (i.e. Soccer, Football, Gymnastics, Baseball,
Cheerleading, Martial Arts, etc.)? ________N _______Y, List: _________________________________________________
__________________________________________________________________________________________________
Has your child ever been involved in a car accident? ______N ______Y, List: ____________________________________
Has your child ever been sen on an emergency basis? ______N ______Y, List: ___________________________________
Other traumas Not Described above? ______N ______Y, List: _______________________________________________
Prior Surgery: ______N ______Y, List: ___________________________________________________________________
Menarche: ______N ______Y, Age: ______
Childhood Diseases:
Chicken Pox
N / Y, Age ______
Mumps
N / Y, Age ______
Rubella
N / Y, Age ______
Whooping Cough
N / Y, Age ______
Rubeola
N / Y, Age ______
Other
N / Y, Age ______
WE ARE HERE TO SERVE YOU, AND ENCOURAGE YOU TO ASK QUESTIONS.
YOUR PARTICIPATION IS VITAL AND WILL HELP DETERMINE YOUR RESULTS.
AUTHORIZATION FOR CARE OF MINOR
I hereby authorize this office and its Doctors to administer care to my Son / Daughter as they deem necessary. I clearly
understand and agree that I am personally responsible for payment of all fees charged by this office.
Name of Insurance Company ______________________________________ Policy# ______________________________
Signed ______________________________ Witnessed ___________________________ Date _____/_____/__________
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