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Pediatric Intake Paperwork
Section 1: Demographics
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Indicates required field
Name:
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First
Last
Prefers to be called:
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Birth date (mm/dd/yyyy):
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Parent or Guardian's Name:
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Height:
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Weight:
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Age:
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Gender
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Male
Female
Home Address:
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Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
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Parent Cell Phone Number:
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Parent Email Address:
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Preferred Method of Contact:
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Home Phone
Cell Phone
E-mail
How were you referred to our office?
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Section 2: Today's Visit
My child is here for a specific issue:
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Yes
No
If No, please go directly to section 3.
Reasons for seeking care:
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Have you seen any other healthcare providers for this condition?
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Yes
No
If yes, what other provider has your child seen?
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Prior Interventions: (What have you done to try and relieve the symptoms?)
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Section 3: General Health
Please check any current or past issues your child has had from this list below:
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ADHD
Allergies
Anemia
Arm/Elbow Pain
Arthritis
Asthma
Autism
Backaches
Bed Wetting
Behavior Problmes
Blood Disorders
Chest Pain
Chronic Ear Infections
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Constipation
Convulsions
Diabetes
Diarrhea
Digestive Issues
Dizziness
Fainting
Frequent Colds
Growing Pains
Headaches
Heart Condition
Hernia
Hyperactivity
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Hypertension
Trouble Sleeping
Joint Pain
Knee/Foot Pain
Leg/Hip Pain
Lyme Disease
Muscle Pain
Neck Pain
Pain Urinating
Paralysis
Poor Appetite
Rashes/Hives
Scoliosis
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Sinus Trouble
Sprains/Strains
Stomach Aches
Other
Previous Chiropractor(s):
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Reason for Care:
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Name of Pediatrician:
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Date of Last Pediatrician Visit:
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Please list any medications your child is taking with reason for use (prescription and over the counter):
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Please list any nutritional supplements/vitamins your child is currently taking:
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Section 4: Injury/Surgery History
Past Injuries - Does your child have a history of any of the following?
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Fractured or broken bone
Spine or nervous system disorder
Being knocked unconscious
Injury in an accident
Bad fall or injury
Other
None of the above
Has your child had any surgeries?
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Yes
No
If yes, please describe with dates:
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Section 5: Health Goals
People seek chiropractic care for a variety of reasons. Some people seek symptom relief, others want to correct the cause of the symptoms, and some are seeking to better their health in general. In our office, you and the doctor will discuss your health and current health issues, and choose a plan that is best for your needs.
As of right now, let us know what type of care you are seeking:
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Relief Care: Symptomatic relief of pain or discomfort (a temporary fix to an underlying problem)
Corrective Care: Correcting and relieving the cause of the problem, as well as the symptoms arising from it
Comprehensive Wellness Care: Achieving a high state of health and function within the body
Not sure yet
Section 6: Acknowledgements
To set clear expectations, improve communication and help you get the best results, please read each statement and initial your agreement.
I instruct the chiropractor to deliver the care that, in her professional judgment, can best help my child in my restoration of his/her health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine, and does not proclaim to cure any named disease or entity.
Initials:
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I may request a copy of the Privacy Policy and understand it describes how my (or my child's) personal health information is protected.
Initials:
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I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my child's care in this office.
Initials
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I acknowledge that I am responsible for the timely payment of any and all services my child receives.
Initials:
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To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my child's health concern or health issues.
Initials
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