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New Pediatric Patient Health History Form
Home
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New Pediatric Patient Health History Form
New Pediatric Patient Health History Form
Kurt Abel
2021-08-04T19:25:07+00:00
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Patient Data
Patient Name
(Required)
First
Last
Date
(Required)
Month
Day
Year
Parent/Guardian Name
(Required)
First
Last
Parent/Guardian Email
(Required)
Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.
Primary Pediatrician's Name & Phone Number
(Required)
Has your child ever been treated by a chiropractor?
(Required)
Yes
No
When was your child last treated?
(Required)
Mailing Address
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Parent/Guardian Cell Phone
Parent/Guardian Home Phone
Referred By
Age
(Required)
Date of Birth
(Required)
Month
Day
Year
Number of Children in the Household
(Required)
If you have multiple children, list the order of birth for your child.
Parent/Guardian Occupation
(Required)
Parent/Guardian Employer
Marital Status
(Required)
Married
Divorced
Separated
Widowed
Single
Emergency Contact
(Required)
Emergency Contact Phone
(Required)
Homeschooled?
Yes
No
Child's School
School City/State
Grade?
Dietary Assessment - How Often Does Your Child Eat the following:
Beans, peas, lentils
3 times daily
daily
weekly
monthly
Breads, cereals, grains
3 times daily
daily
weekly
monthly
Candy
3 times daily
daily
weekly
monthly
Dairy products
3 times daily
daily
weekly
monthly
Eggs
3 times daily
daily
weekly
monthly
Fruits
3 times daily
daily
weekly
monthly
Meats
3 times daily
daily
weekly
monthly
Poultry, fish
3 times daily
daily
weekly
monthly
Sodas
3 times daily
daily
weekly
monthly
Vegetables, green
3 times daily
daily
weekly
monthly
Vegetables, orange
3 times daily
daily
weekly
monthly
Vegetables, yellow
3 times daily
daily
weekly
monthly
How much water does your child consume daily?
(Required)
What vitamin/supplements does your child take? (if none enter n/a)
(Required)
How often?
(Required)
Medical History
Please check if child has ever had any of the following:
Anemia
Asthma
Bronchitis/Bronchiolitis
Bronchopulmonary Dysplasia (BPD)
Chicken Pox
Hepatitis
Immune Deficiency/HIV
Measles (10-day)
Measles Rubella (3-day)
Mumps
Pneumonia
Sickle Cell Disease
Whooping Cough
General
Anxiety
Autism
Chills
Depression
Dizziness
Fainting
Forgetfulness
Headache
Loss of sleep
Mood swings
Nervousness
Numbness
Scoliosis
Sweating
Tiredness
Weight loss/gain
RESPIRATORY
Asthma
Pneumothorax (Collapsed lung)
Chronic Sinusitis
Ear tube placement
Emphysema
NOSE/THROAT/CHEST
Difficulty breathing
Difficulty swallowing
Frequent colds
Hoarseness
Nosebleeds
Persistent cough
Sinus problems
Sore throats
Strep Throat
Tonsil infections
Wheezing
How often does your child get nosebleeds?
HEARING/SPEECH
Difficulty hearing
Earache
Ear infections
Hoarseness
Speech problems
Please describe any speech problems:
CARDIOVASCULAR
Breathing problems
Chest pain
Irregular heart beat
GASTROINTESTINAL
Appetite poor
Bloody or dark stools
Constipation
Diarrhea
Excessive hunger
Excessive thirst
Nausea
Rectal bleeding
Stomachaches
Vomiting
Worms
EYES
Crossed or wandering eyes
Eye irritation
Headaches
Vision problems
DENTAL
Bleeding gums
Grinding teeth
Sensitivity to hot/cold
Thumb-sucking
Dental check-up
Brush
Floss
Date of last dental exam?
How often does your child brush teeth?
How often does your child floss?
MUSCLE/JOINT/BONE
Coordination problems
Pain, weakness, swelling in arms
Pain, weakness, swelling in back
Pain, weakness, swelling in feet
Pain, weakness, swelling in hands
Pain, weakness, swelling in hips
Pain, weakness, swelling in legs
Pain, weakness, swelling in neck
Pain, weakness, swelling in shoulders
Please describe any coordination problems
GENITO-URINARY
Bed-wetting
Blood in urine
Diaper rash, persistent
Discharge from vagina or penis
Frequent urination
Painful urination
Unusual urine odor
SKIN
Bruise easily
Change in moles
Eczema
Hives
Itching
Rash
Scars
Sores that won’t heal
Has your child ever:
Broken bones?
(Required)
yes
no
Breifly explain any broken bones
(Required)
Been hospitalized?
(Required)
yes
no
Breifly explain hospitalizations
(Required)
Had sprains/strains?
(Required)
yes
no
Breifly explain any sprains/strains
(Required)
Been struck unconscious?
(Required)
yes
no
Breifly explain being struck unconscious
(Required)
Had surgery?
(Required)
yes
no
Breifly explain any surgeries
(Required)
Had diagnostic imaging (x-rays, MRI, ultrasound)
(Required)
yes
no
Breifly explain any diagnostic imaging
(Required)
Family History
Please list any family members and any past or current health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.) If none, please enter none.
(Required)
Additional Information
Has your child been vaccinated?
(Required)
yes
no
When was your child's first vaccination?
(Required)
When was your child's last vaccination?
(Required)
How many hours per night does your child sleep?
(Required)
How many times a year does your child get sick?
(Required)
How long do these episodes last?
(Required)
Does your child self adjust their neck or spine?
(Required)
Yes
No
How often does your child self adjust?
(Required)
Daily
Infrequently
Does your child participate in sports?
(Required)
Yes
No
Please list the types of sports and how often they practice per week:
(Required)
Consent
(Required)
Please check this box confirm that you have read and filled out all the information above. Please note: If you cannot make your appointment, please notify us within 24 BUSINESS hours. There is a $20.00 fee for any cancellation or rescheduled appointments less than 24 BUSINESS hours before your scheduled time or missed appointments.
Signature
(Required)
Please use your mouse or finger to sign in this box.
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