Pediatric History

For children 12 years and under

Name

Phone

Email

Address

Gender

Male

Female

Weight

Height

Date of birth

Month

Day

Year

Parent(s)/ Guardian name(s)

Have any doctors been seen for this condition? If Yes, list Doctor name(s) and prior treatments

Family History:

Name of Pediatrician

Date of last visit

Number of antibiotics your child has taken in his/her lifetime

Number of doses of other prescription medications your child has taken in his/her life time, pleast list

Vaccination History:

Prenatal History:

Name of Obstetrician/ midwife:

Any Complications during pregnancy?

How many Ultrasounds did you have during pregnancy

Did you take any medications during pregnancy? Pleast list

Cigarette/ Alcohol use during pregnancy

Yes

No

Location of birth

Hospital

Home

Birthing center

Birthing intervention:

Forceps

Vacuum Extraction

Caesarian Section (Emergency)

Caesarian Section (Planned)

List any complications during delivery

Genetic Disorders and Disabilities:

Birth Weight

Birth Length

APGAR Scores

Feeding History

Breast Fed

Yes

No

How Long

Formula Fed

Yes

No

How Long

When was he/she introduced to solids

When was he/she introduced to Cows Milk

Food/Juice allergies or Sensitivities

Developmental History

During the following developmental stages 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 (spinnal nerve interference). At what age was your child able to:

Respond to sound

Respond to Visual stimuli

Hold head up

Sit up

Walk Alone

Cross Crawl

Stand alone

According to the National Safety Council, approximately 50% of children fall head-first from a high place during the first year of life. Has your child had a head-first fall? If yes please explain

Haw your child been involved in any high contact sports? (Soccer, Football, Gymnastics, Baseball, etc.)

Has your child ever been in a car accident. If yes please explain

Any other traumas, surgeries, Health concerns or emergency events not listed above?

Initials

I declare that the info I’ve provided is accurate and complete.