New Patient Intake Form - Child

(Internal use) Date: ______________ (Internal use) File # ______________

Personal Profile

Please complete this form on behalf of the child receiving care.

Child's Full Name *

Name of Parent(s)/Guardian(s) *

Address *

City *

Postal code *

Phone *

Parent's Phone *

Gender *

Age *

Date of birth *

Current height *

Current weight *

Do you have siblings? If yes, what are their names and ages? *

Health Coverage Information

Who is your family doctor? *

Phone Number of your family doctor: *

Do you have extended health insurance? *

If yes, with which insurance company?

$ Participation/Year

Insurance Renewal Date

How were you referred to our office? *

Have you ever received chiropractic care before? *

Is yes, please provide details of when, the doctor's name and # years under care.

Health Concerns

Is this visit for a general wellness checkup? *

What is your reason for this visit? *

Date of symptom onset? *

Please describe the onset of this symptom(s): *

Duration of problem: *

Pattern of problem: *

Have you had any prior occurrence or episodes of this issue? *

Please describe how this issue impacts your daily activities and how your body functions: *

Please describe any factors that initiate, aggravate or relieve your symptoms: *

If you don't get a problem corrected, do you think it will get worse in the next... *

1 year

2 years

5 years

Growth & Development

Was the infant alert and responsive within 12 hours of delivery? YES/NO Please explain: *

Has your child met their developmental milestones at the appropriate times? YES/NO Please explain: *

Is their sleeping pattern normal? YES/NO Please explain: *

List any health problems (Cancer, Diabetes, Heart disease, etc.) on father/mother's side of family or in siblings: *

Stressors

Since problems that arise are related to many types of stressors and traumas, please fill in the following information:

Chemical

Was the baby breast-fed? If yes, for how long? *

Food Intolerance? If yes, please describe: *

Any illness of the mother during pregnancy? *

Any supplements of mother during pregnancy? *

Any drugs taken during pregnancy? *

Any exposures to ultrasound? If so, how many and what was the medical reason? *

Any Invasive procedures? (E.g. Amniocentesis, CVS) *

Any smokers in the home? YES/NO *

Any vaccinations? If yes, which ones and any reactions: *

Any antibiotics? If yes, which ones and any reactions: *

Total number of courses of antibiotics: *

Psychosocial

Any difficulties with lactation, latching or sucking? *

Any behavioural problems? If yes, when was the onset? *

Any night terrors, sleep walking, difficulty sleeping? If yes, please specify: *

Does your child seem normal for their age? Please explain: *

Traumatic

Any traumas during pregnancy (falls, accidents)? YES/NO Please explain: *

Any evidence of birth trauma: (E.g. bruises, odd shaped head, stuck in birth canal, fast or excessively long birth, respiratory depression, cord around neck) *

Any falls from couches, beds, change tables? YES/NO Please explain: *

Any traumas with bruising, cuts, stitches, fractures? YES/NO Please explain: *

Any hospitalizations? YES/NO Please explain: *

Any surgeries or organs removed? YES/NO Please explain: *

Any history of ear infections, regular colds, strep throat, croup, pneumonia or bronchitis? YES/NO Please explain: *