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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.


If you have questions, or if for any reason you would rather us send you forms through mail or email, don't hesitate to call us at:

Bozeman Office: 406.585.7000
or email us at info@abundanthealthchiro.net

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Click below to request an appointment for you or a family member.

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New to chiropractic care? Looking for a family chiropractor?

Call us at (406) 585-7000 to set up a complimentary 10-minute consultation.