Pediatric History Form

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Pediatric History Form
Patient Name______________________________ SS#__________________
Name of Parents / Guardians_____________________________________
Address ________________________________City _______________State _____Zip___________
Home Phone_______________ Work Phone_________________ Email Address___________________
Birth Date ___________ Sex______ Weight___________ Height_______ Number of siblings_______
Who referred you to us? _________________________________________
Reason for seeking chiropractic care:______________________________________________________
Other Doctors seen for this condition Y/N Specialty: _________________________________________
Prior treatment and outcome: ____________________________________________________________
Other Health Problems: ________________________________________________________________
Symptoms: Please check any current or past problems your child has on the list below:
_Dizziness
_Allergies
_Diarrhea
_Broken bones
_ADHD
_Runny Nose
_Poor Appetite
_Sprains/Strains
_Backaches
_Itchy Eyes
_Hyperactivity
_Hernias
_Heart Condition
_Rashes
_Behavioral
_Neck Pain
_Chronic Earaches
_Unusual Moles
_Poor Memory
_Arm/Elbow Pain
_Diabetes
_Neuritis
_Insomnia
_Leg/Hip Pain
_Tuberculosis
_Digestive
_Nightmares
_Knee/Foot Pain
_Hypertension
_Sinus Trouble
_Bed Wetting
_Growing pains
_Fever/Chills
_Cough/Wheeze
_Pain Urinating
_Joint Pain
_Frequent Colds
_Chest Pain
_Convulsions _Paralysis
_Scoliosis
_Arthritis
_Constipation
_Muscle Pain
_Blood disorders
_Headaches
_Anemia
_Fainting
_Stomach Aches _Other
_Asthma
_Rheumatic Fever
Health History:
Name of Pediatrician: ________________________________________ Date of last visit _____________
Reason for visit: ________________________________________________________________________
Medications and conditions being treated: ___________________________________________________
Has your child ever taken antibiotics? Y/N Condition treated: ____________________________________
Has your child been injured participating in contact sports (Soccer, Football, Martial Arts…) Y/N
If yes, describe (Sprain, Broken Bone, Head Trauma…) ________________________________________
Has your child ever been involved in a car accident? Y/N Date & Injuries __________________________
Has your child ever fallen head first from (Changing Table, Bed, Stairs…) Y/N ______________________
Other traumas not described above? Y/N Type & Date: _________________________________________
Prior surgery: Y/N Type and Date:______________________________ Menarche: Y/N Age:________
Prenatal History
Location of Birth: O Home O Birthing Center O Hospital O Stepchild O Adopted
Complications during pregnancy: Y/N List: __________________________________________________
Ultrasounds during pregnancy: N Y Number: __________
Medications during pregnancy/delivery: Y/N List: _____________________________________________
Cigarette / Alcohol use during pregnancy: Y/N
Birth intervention: O Forceps O Vacuum O Caesarian, Why?_____________________________________
Complications during delivery: Y/N List: ____________________________________________________
Genetic disorders or disabilities: Y/N List: ___________________________________________________
Birth weight________ Birth length_________ APGAR scores: 1 min _____ 5 min _____
Feeding history
Breast Fed: Y/N How long’?___________ Formula fed: Y/N How long’?___________
Type:______________ Introduced to solids at _____ months. Cow’s milk at _____ months
Food / juice allergies or intolerances Y/N List: ________________________________________
Developmental History
Sleep (Hrs per night) _______ Naps (number & lengths) _____________ Problems sleeping __________
At hat age was your child able to: Crawl __ Sit alone __ Stand alone __ Walk alone __ Say words __

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