New Pediatric Patient Health History Form - Lander Chiropractic

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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

When was your child last treated?(Required)

Mailing Address

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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)

Emergency Contact(Required)

Emergency Contact Phone(Required)

Homeschooled?

Yes

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

Breifly explain any broken bones(Required)

Been hospitalized?(Required)

yes

Breifly explain hospitalizations(Required)

Had sprains/strains?(Required)

yes

Breifly explain any sprains/strains(Required)

Been struck unconscious?(Required)

yes

Breifly explain being struck unconscious(Required)

Had surgery?(Required)

yes

Breifly explain any surgeries(Required)

Had diagnostic imaging (x-rays, MRI, ultrasound)(Required)

yes

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

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

How often does your child self adjust?(Required)

Daily

Infrequently

Does your child participate in sports?(Required)

Yes

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.