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

Check any of the folling conditions your child has experienced during the past six months

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?

Please mark all childhood diseases that may apply

Initials

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