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Pediatric Patient Form

Abundant Health Family Chiropractic, Bozeman, MT

Pediatric Form

Please complete this form in its entirety. ALL INFORMATION IS KEPT CONFIDENTIAL.

Patient Information:

General Information:

If referred to my office, by whom?

Purpose of visit/ specific concern:

Has your child seen other Doctors for this condition?

Doctor's Name:

Treatment:

Has your child ever been to a chiropractor before?

Chiropractor's Name

When was the last visit?

Reason for Care:

Does your child have other Health Problems?

Please Describe:

Name of Pediatrician:

Date of Last Visit:

Number of Doses of Antibiotics your child has taken:

Number of Doses of Prescription Medication
your child has taken:

Vaccination History:

Prenatal History:

Name of Obstetrician/ Midwife:

Complications During Pregnancy?

List:

Complications During Delivery?

List:

Ultrasounds During Pregnancy?

How Many?

Medications During Pregnancy?

List:

Cigarettes/ Alcohol use During Pregnancy?

Please Describe:

Location of Birth:

Birth Intervention:

Birth Height:

Birth Weight:

Feeding History:

Breastfed?

How Long?

Formula fed?

How Long?

Introduced Solids at:

months

Introduced Cows Milk at:

months

Food/ Juice Allergies or Intolerances?

List:

Developmental History:

During the following times your child's spine is most vulnerable to stress and should routinely be checked by a doctor of chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference). At what age was your child able to:

According to the National Safety Council, approximately 50% of children fall from a high place during their first year of life (e.g. a bed, changing table, down stairs etc). Was this the case with you child?

Please Describe:

Is/ Has your child been involved in any high impact or contact type sports (i.e. soccer, football, gymnastics, baseball, cheerleading, martial arts, etc.)?

List:

Has your child ever been involved in a car accident?

Please Describe:

Has your child been seen on an emergency basis?

Reason:

Other traumas not described above?

Please Describe:

Prior Surgery?

List:

Menarche?

Age:

Consent to Treat a Minor:

I hereby request and authorize this office and its doctor to perform diagnostic test and render chiropractic care as she deems necessary, to my minor child: .

As of this date, I have the legal right to select and authorize health care services for the minor child named above.

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New to chiropractic care? Looking for a family chiropractor?

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