Pediatric History Form (Page 2 of 2) in pdf

Pediatric History Form Page 2

Childhood Diseases

O Chicken Pox - Age ___ O Mumps - Age ___ O Rubella - Age ___ O Whooping cough - Age ___

O Measles - Age ___ O Meningitis - Age ___ O Tuberculosis - Age ___ O Other - Age _________

Vaccination History:

O HBV / Hep B (Hepatitis B) – Age __ O MMR (Measles, Mumps, Rubella) – Age __

O DTP or O DTaP (Diphtheria, Tetanus, Pertussis) – Age __ O Varicella (Chicken Pox) – Age __

O HbCV / Hib (H. influenzae type b conjugate) – Age __ O PCV (Pneumoccocal) – Age __

O OPV (Oral Polio Vaccine) or O IPV (Inactivated Poliovirus) – Age __

Adverse Reactions to Any Vaccine? Y/N List: _________________________________________

Insurance

Do you have medical insurance? Y/N Insurance Company Name ____________________________

Policy Number ______________________Insurance Company Phone number _________________

Insured’s Name ______________________Relationship to patient ____________________________

Insured’s DOB ______________________Insured’s SS# ___________________________________

Insured’s Employer _________________ Insured’s Employee Address_________________________

CONSENT TO CHIROPRACTIC CARE

I certify that the information that I have supplied is correct and accurate to the best of my knowledge.

I, _____________________________, being the parent or legal guardian of _________________________ hereby grant

permission for my child to receive chiropractic care.

Signed ______________________________________Witnessed ________________________________

Date _______________

Pediatric History Form Page 2