PEDIATRIC PAPERWORK

INTRODUCTION PATIENT CASE HISTORY
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Information
Name

First NameMiddle NameLast Name
Preferred Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home

Area CodePhone Number
Work

Area CodePhone Number
Mobile

Area CodePhone Number
Mobile Carrier
Email
example@example.com
Social Security Number
Gender
Marital Status

Other
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Status
Employed
Employer
Referred By
Ethnicity

Other
Race

Other
Preferred Language
Smoking Status
Emergency Contact Information
Full Name

First NameLast Name
Relationship
Home

Area CodePhone Number
Mobile

Area CodePhone Number
Primary Care Physician
Doctor's Phone

Area CodePhone Number
Financial Information
Financial Information

Other
Primary Insurance
Name

First NameLast Name
Relation to Insured

Other
Insured's Name (If Other than Self)

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number

Area CodePhone Number
Gender
Address

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Insurance
Name

First NameLast Name
Relation to Insured

Other
Insured's Name (If Other than Self)

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number

Area CodePhone Number
Gender
Address

Street Address

Street Address Line 2

CityState

Zip Code
Who is responsible for payment?

Other
Full Name (Other than Self)

First NameLast Name
Relationship
If other
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
It is Usual and Customary to Pay for Services as Render Unless Otherwise Arranged

Pediatric Case History
History of Current Condition
Describe Major Complaint
Began When?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Describe how this began
Grade Intensity/Severity of Complaint
How frequent is the complaint present?
Does anything make the complaint better?
Does anything make the complaint worse?
Which daily activities are being affected by this condition?
Describe
For this CURRENT condition, have you:
Received any other treatment?

Other
Where?
Had any previous Surgery or Interventions in this area?
Describe
Taken any Medications?
OTC/Prescriptions
Had any diagnostic testing?

Other
When and Where?
Describe any Secondary Complaints
Health History
Medications
Allergies to Medications
List. If none, write none.
Current Medications
(Over-the-counter or Prescription) List. If none, write none.
Past Health History
Surgeries (Date, Type and Reason)
(Please list any past) List. If none, write none.
Major Injuries/Traumas
List. If none, write none.
Major Hospitalizations
List. If none, write none.
Family Health History
List relevant major health problems of immediate relatives
Please mark N/A if not relevant
Deaths in immediate family
Cause and at what Age?
Prenatal History
Born where?
Birth Weight
Birth Length
Interventions
Complications
If none, write none.
Medications during pregnancy
List. If none, write none.
Feeding and Development History
Breast fed
How long?
Formula
What type?
Food allergies or intolerances?
Please describe
If answer is Yes
Rolling over
Crawling
Sitting
Walking
Sleep
Hours/night
Sleep well
Childhood diseases

Other
Has child been vaccinated?
Any adverse reactions?
Social and Occupational History
Level of Education Completed
Lifestyle
Hobbies, Rec. Activities, Exercise, Diet, Work, Vitamins
Review of Systems
Are you currently experiencing any of these symptoms? (Check all the apply)

Many of the following conditions respond to Chiropractic and Acupuncture treatment.
General (constitutional)
Musculoskeletal

Other
Neurological

Other
Mind/Stress

Other
Genitourinary

Other
Gastrointestinal

Other
Cardiovascular & Heart

Other
Respiratory

Other
Eyes and Vision

Other
Ears, Nose and Throat

Other
Endocrine, Hematologic and Lymphatic

Other
Skin and Breasts

Other
Women Only
Are you pregnant?
Yes - Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
No - Last Menstruation Period

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other
Pregnancies with Outcome & Date
Comments
I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office to provide me with chiropractic care, diagnostic testing, and/or therapeutic services, in accordance with state's statues.
Patient or Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: