Pediatric Health History
Please use this form for anyone 14 years and younger.
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Child's Name *
Parent's Name *
Age *
Date of Birth *
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Sex *
Siblings Names and Ages *
Email *
Street Address *
City *
State *
Zip Code *
Country *
Phone Number *
Family Doctor and Contact Information *
Whom may we thank for referring you? *
Has your child ever received chiropractic care? If yes, who was your child's previous Doctor of Chiropractic? *
Date and reason for last visit *
Other professionals seen for this condition *
Results with that treatment? *
Recent tests done (Blood work/Urine/X-rays/Other) Please explain and include dates *
What is the purpose of your child's visit? *
Required
Present Health Concerns
What is the current health concern(s), if any? *
When did this problem begin? Is it occasional, frequent, constant, or intermittent? *
Does this problem radiate? If yes, where? *
What makes it worse? What makes it better? *
Is the problem worse during a certain time of the day? If yes, when? *
Does this interfere with the child's sleep? Eating? Daily routine? *
Is this becoming worse? *
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?
Birth History
What was the child's gestational age at birth? Birth weight? Birth length? *
Where was your child's birth? (Home/In a birthing center/Hospital/Other) *
Was the birth considered medical or by midwife? What was the duration in hours? *
Was the child born cephalic (head first) or breech (feet first)? *
Were there any complications? If yes, please explain. *
Assistance used during delivery: (Forceps/Vacuum extraction/C-section/Episiotomy) *
Was labor spontaneous or induced? *
Were medications or epidurals given to the mother during birth? (Yes/No) *
APGAR Score at Birth ____/10? After 5 minutes ----/10? *
Is there anything else we need to know about the birth?
Growth & Development
Was the infant alert and responsive within 12 hours of delivery? (Yes/No)If no, please explain *
At what ages did the child:Respond to sound, Hold up head, Sit alone, Crawl, Follow an object, Vocalize, Teethe, and Walk *
Does your child sleep on their front, back, or side? *
Do you consider the child's sleeping pattern normal? (Yes/No) How many hours per day? If no, please explain. *
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. *
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 *
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. *
Any falls from couches, beds, change tables, etc? (Yes/No)If yes, please explain *
Any traumas resulting in bruises, cuts, stitches or fractures? (Yes/No)If yes, please explain *
Any hospitalizations or surgeries? (Yes/No)If yes, please explain *
Any sports played? *
Is a school backpack used? Is it heavy or light? *
Chemical Stressors
Was the child breastfed? If yes, how long? *
Formula introduced at what age? Which formula? Introduction of cow's milk at what age? *
Began solid food at what age? Types of solid foods? *
Food/Juice intolerance? (Yes/No) If yes, please explain. *
Is your child on or have taken any medications? (Yes/No) If yes, what medications? *
During the mother's pregnancy, did the mother smoke? (Yes/No) If yes, how much? *
During the mother's pregnancy, did the mother drink alcohol? (Yes/No) If yes, how much? *
Any illnesses during the pregnancy? (Yes/No) If yes, please describe. *
Please describe your child's vaccine history *
Has your child ever had a negative reaction from a vaccine?
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If yes, please describe the reaction.
Any supplements taken during the pregnancy? (Yes/No) If yes, please describe. *
Any drugs taken during the pregnancy? (Yes/No) If yes, please describe. *
Any ultrasounds? How many and for what reason? *
Any invasive procedures during pregnancy (ie amniocentesis, Chorionic villi sampling, ect.)? (Yes/No) If yes, please describe. *
Any pets at home? *
Any smokers in the home? *
Any antibiotics given? (Yes/No) If yes, for what reason? *
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) *
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) *
Psychosocial Stressors
Any difficulties with lactation? *
Any problems with bonding? *
Any behavioral problems? *
Any inattention? *
Any hyperactivity or restlessness? *
Any compulsiveness? *
Any difficulties at daycare or school? *
Any challenges with learning deficiencies?
Any night terrors, sleep walking, difficulty sleeping? *
Any prolonged temper tantrums or separation anxiety? *
Is the child in daycare? What was their age when they began daycare? *
Is there a nanny or regular sitter during the day if both parents work? *
Is the child home schooled? By whom? *
Average number of hours of television per week? Hours of video games per week? *
Does you child have a cell phone? How often do they text or use the phone? *
Do you feel that your child's social and emotional development is normal for their age? *
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
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Today's Date *
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