New Chiropractic Patient Intake Form - Pediatric

Patient Information

Name

First Last

Date of Birth

Gender at Birth

Male
Female

Personal Health #

Height

Specify feet or meters

Weight

Specify lbs or kg

Mailing Address

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

Home phone

Cell phone

Email

Handedness

Right-handed
Left-handed

How did you hear about our clinic?

Referral
Social media
Internet search

Whom may we thank for referring us to you?

Parent/Legal Guardian

Name

First Last

Home phone

Cell phone

Email

Employer

Emergency Contact

Name

First Last

Phone

Relationship

Primary Care Physician

Name

First Last

Phone

Last visit to your doctor

Do you have private health insurance through a medical plan?

Yes
No

Insurance Information

Policy holder's name

First Last

Relationship to the patient

Policy holder's date of birth

Policy group number

ID certificate number

Is your problem a result of an injury?

Yes
No

When did the accident/injury occur?

Chiropractic Information

Please list the condition(s) that brought you to this office

click the + to add additional lines

Have you previously been treated for your condition(s) by a chiropractor?

Yes
No

What is the name of your previous chiropractor?

First Last

When was your last chiropractic adjustment?

Rate the results of the your last chiropractic adjustment

Good
Fair
Poor

Since when have you been suffering with this condition?

Please list the regions of pain and severity

Pain region	Pain severity (1=least, 10=worst)

click the + to add additional lines

What type of pain are you experiencing?

Is the pain getting better or worse since it started?

Better
Worse

How did the pain occur?

Suddenly
Gradually

How often does it bother you?

Constantly
Frequently
Daily
Occasionally

Does the pain wake you up at night?

Yes
No

Do your symptoms interfere with daily life?

Yes
No

Are your symptoms worse during certain times of the day?

Yes
No

Please describe:

Do changes in the weather affect your symptoms?

Yes
No

What makes the pain better?

What makes the pain worse?

What activities aggravate your symptoms?

Medical History

We focus on your ability to be healthy. Our first goal is to address the issues that brought you here and, secondly, to offer you the opportunity to continue improving your health and wellness. Stresses can accumulate over many years and affect your health. Answering the following questions will give us a profile of the specific pressures you have faced in your lifetime.

Do you play contact sports?

Yes
No
Not sure

Have you had any serious falls?

Yes
No
Not sure

Have you suffered any fractured bones?

Yes
No
Not sure

Have you had any surgery?

Yes
No
Not sure

Is there prolonged use of medicine (e.g. inhaler, anitbiotic)?

Yes
No
Not sure

Have you had any surgery?

Yes
No

Were you involved in any accidents (car/work)?

Yes
No

Is there any prolonged use of medicine (e.g. inhaler, Antibiotic)?

Yes
No

Do you wear orthotics?

Yes
No

Do you have artifical joints?

Yes
No

Which joint?

List past surgeries:

Type of surgery	Date of surgery

click the + to add additional lines

List past fractures:

Type of fracture	Date of fracture

click the + to add additional lines

Have you had X-rays?

Yes
No

When was your last X-ray?

List all prescription and non-prescription medications you are taking

Name of Drug	Dosage	Frequency

click the + to add additional lines

List all supplements you are taking

Name of supplement	Dosage	Frequency

click the + to add additional lines

CURRENT SYMPTOMS

Check any symptoms that you are experiencing, even if they do not seem related to your current problem.

General Symptoms

Neurologic Symptoms

Respiratory Symptoms

Asthma
Bronchitis
Chronic cough
Difficulty breathing
Shortness of breath
Spitting blood and phlegm
Tuberculosis
Wheezing

Muscle and Joint Symptoms

Genito-Urinary Symptoms

Bedwetting
Blood in urine
Frequent urination
Kidney infection
Kidney Stones
Prostate problems
Trouble urinating

Cardiovascular Symptoms

Ear, Nose and Throat Symptoms

Ear ache
Enlarged thyroid
Frequent colds
Hay fever
Nasal blockage
Nosebleeds
Pain behind the eyes
Sinusitus
Sore throat

Gastro-Intestinal Symptoms

Skin or Allergies

Bruising easily
Dryness
Eczema
Itching
Rash

Has any member of your immediate family suffered from the following?

Diabetes
Heart problems
Kidney problems
Hypertension
Stroke
Cancer
Back pain

Lifestyle and Habits

Do you do any of the following?

Eat sugary foods
Eat salty foods
Use artificial sweeteners
Get enough sleep

How much water do you drink?

Less than 4 glasses per day
More than 4 glasses per day
None

How much do you exercise?

Less than 2X a week
More than 2X a week
Every day
I don't exercise

Authorization

Consent

I, the undersigned, certify that all the medical information provided is true to the best of my knowledge, and I have not knowingly omitted any information.

Signature

Name

This field is for validation purposes and should be left unchanged.