Pediatric Health History
Please use this form for anyone 14 years and younger.
Child's Name *
Your answer
Parent's Name *
Your answer
Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Siblings Names and Ages *
Your answer
Email *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Country *
Your answer
Phone Number *
Your answer
Family Doctor and Contact Information *
Your answer
Whom may we thank for referring you? *
Your answer
Has your child ever received chiropractic care? If yes, who was your child's previous Doctor of Chiropractic? *
Your answer
Date and reason for last visit *
Your answer
Other professionals seen for this condition *
Your answer
Results with that treatment? *
Your answer
Recent tests done (Blood work/Urine/X-rays/Other) Please explain and include dates *
Your answer
What is the purpose of your child's visit? *
Required
Present Health Concerns
What is the current health concern(s), if any? *
Your answer
When did this problem begin? Is it occasional, frequent, constant, or intermittent? *
Your answer
Does this problem radiate? If yes, where? *
Your answer
What makes it worse? What makes it better? *
Your answer
Is the problem worse during a certain time of the day? If yes, when? *
Your answer
Does this interfere with the child's sleep? Eating? Daily routine? *
Your answer
Is this becoming worse? *
Your answer
Often, seemingly unrelated symptoms can manifest as other health concerns. Please mark if your child has had any of the following: *
Required
Any other concerns not shown above?
Your answer
Birth History
What was the child's gestational age at birth? Birth weight? Birth length? *
Your answer
Where was your child's birth? (Home/In a birthing center/Hospital/Other) *
Your answer
Was the birth considered medical or by midwife? What was the duration in hours? *
Your answer
Was the child born cephalic (head first) or breech (feet first)? *
Your answer
Were there any complications? If yes, please explain. *
Your answer
Assistance used during delivery: (Forceps/Vacuum extraction/C-section/Episiotomy) *
Your answer
Was labor spontaneous or induced? *
Your answer
Were medications or epidurals given to the mother during birth? (Yes/No) *
Your answer
APGAR Score at Birth ____/10? After 5 minutes ----/10? *
Your answer
Is there anything else we need to know about the birth?
Your answer
Growth & Development
Was the infant alert and responsive within 12 hours of delivery? (Yes/No)If no, please explain *
Your answer
At what ages did the child:Respond to sound, Hold up head, Sit alone, Crawl, Follow an object, Vocalize, Teethe, and Walk *
Your answer
Does your child sleep on their front, back, or side? *
Your answer
Do you consider the child's sleeping pattern normal? (Yes/No) How many hours per day? If no, please explain. *
Your answer
Family Health History
Please note any health problems (ie: cancer, hereditary conditions, diabetes, heart disease) that are present in the mother's family, father's family, and siblings. *
Your answer
Physical Stressors
Since problems that chiropractors look for and detect can be related to many types of stressors, the following information is also very important to us.
Any traumas to the mother during pregnancy? (ie falls, accidents, etc) (Yes/No)If yes, please explain *
Your answer
Any evidence of birth trauma to the infant? Please list if there was any of the following:bruising, stuck in birth canal, respiratory depression, odd shaped head, fast or excessively long birth, or cord around neck. *
Your answer
Any falls from couches, beds, change tables, etc? (Yes/No)If yes, please explain *
Your answer
Any traumas resulting in bruises, cuts, stitches or fractures? (Yes/No)If yes, please explain *
Your answer
Any hospitalizations or surgeries? (Yes/No)If yes, please explain *
Your answer
Any sports played? *
Your answer
Is a school backpack used? Is it heavy or light? *
Your answer
Chemical Stressors
Was the child breastfed? If yes, how long? *
Your answer
Formula introduced at what age? Which formula? Introduction of cow's milk at what age? *
Your answer
Began solid food at what age? Types of solid foods? *
Your answer
Food/Juice intolerance? (Yes/No) If yes, please explain. *
Your answer
Is your child on or have taken any medications? (Yes/No) If yes, what medications? *
Your answer
During the mother's pregnancy, did the mother smoke? (Yes/No) If yes, how much? *
Your answer
During the mother's pregnancy, did the mother drink alcohol? (Yes/No) If yes, how much? *
Your answer
Any illnesses during the pregnancy? (Yes/No) If yes, please describe. *
Your answer
Please describe your child's vaccine history *
Has your child ever had a negative reaction from a vaccine?
If yes, please describe the reaction.
Your answer
Any supplements taken during the pregnancy? (Yes/No) If yes, please describe. *
Your answer
Any drugs taken during the pregnancy? (Yes/No) If yes, please describe. *
Your answer
Any ultrasounds? How many and for what reason? *
Your answer
Any invasive procedures during pregnancy (ie amniocentesis, Chorionic villi sampling, ect.)? (Yes/No) If yes, please describe. *
Your answer
Any pets at home? *
Your answer
Any smokers in the home? *
Your answer
Any antibiotics given? (Yes/No) If yes, for what reason? *
Your answer
Is the diet organic? *
Do you use '"green products" in your home for cleaning? *
How often does the child receive processed foods, white sugar, gluten (flour), or dairy in their diet?(Never/On weekends/A few times per week/Daily/Nearly each meal/On special occasions) *
Your answer
Are you aware of the impact of nutrition on children's behavior? (Yes/No)Would you like information on nutrition for your child? (Yes/No) *
Your answer
Psychosocial Stressors
Any difficulties with lactation? *
Your answer
Any problems with bonding? *
Your answer
Any behavioral problems? *
Your answer
Any inattention? *
Your answer
Any hyperactivity or restlessness? *
Your answer
Any compulsiveness? *
Your answer
Any difficulties at daycare or school? *
Your answer
Any challenges with learning deficiencies?
Your answer
Any night terrors, sleep walking, difficulty sleeping? *
Your answer
Any prolonged temper tantrums or separation anxiety? *
Your answer
Is the child in daycare? What was their age when they began daycare? *
Your answer
Is there a nanny or regular sitter during the day if both parents work? *
Your answer
Is the child home schooled? By whom? *
Your answer
Average number of hours of television per week? Hours of video games per week? *
Your answer
Does you child have a cell phone? How often do they text or use the phone? *
Your answer
Do you feel that your child's social and emotional development is normal for their age? *
Your answer
Thank you for completing this form. If you have anything to add below, please add notes which can then be discussed with the doctor. If there are any other questions or concerns which you have, please discuss with the doctor.
Other notes
Your answer
Name *
Your answer
Today's Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of Innate Family Chiropractic. Report Abuse - Terms of Service