PEDIATRIC PAPERWORK

INTRODUCTION PATIENT CASE HISTORY
Today's Date

MonthDayYear
Date
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*

MF
Marital Status

MarriedSingleOther
Date of Birth*

MonthDayYear
Date
Student Status

Full StudentPart StudentNon-student
Employed

YesNo
Employer
Referred By
Ethnicity

Hispanic or LatinoOther
Race

AsianAfrican AmericanAmerican Indian or Alaskan NativeNative Hawaii or Pacific IslandWhiteOther
Preferred Language
Smoking Status

Every DaySome DaysFormerNever
Emergency Contact Information
Full Name

First NameLast Name
Relationship

ChildParentSpouseOther
Home

Area CodePhone Number
Mobile

Area CodePhone Number
Primary Care Physician
Doctor's Phone

Area CodePhone Number
Financial Information
Financial Information

InsuranceWorker's CompSelf-Pay (Cash)Personal Injury/AutoOther
Primary Insurance
Name

First NameLast Name
Relation to Insured

SelfSpouseParentChildOther
Insured's Name (If Other than Self)

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Gender

MF
Address

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Insurance
Name

First NameLast Name
Relation to Insured

SelfSpouseParentChildOther
Insured's Name (If Other than Self)

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Gender

MF
Address

Street Address

Street Address Line 2

CityState

Zip Code
Who is responsible for payment?

SelfOther
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
Date
Describe how this began
Grade Intensity/Severity of Complaint

NoneMildModerateSevereVery Severe
How frequent is the complaint present?

Off & OnConstant
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?

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

X-rayMRICTOther
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?

HomeBirthing CenterHospital
Birth Weight
Birth Length
Interventions

NoneForcepsVacuumC-Section
Complications
If none, write none.
Medications during pregnancy
List. If none, write none.
Feeding and Development History
Breast fed

NoYes
How long?
Formula

NoYes
What type?
Food allergies or intolerances?

NoYes
Please describe
If answer is Yes
Rolling over

NoYes
Crawling

NoYes
Sitting

NoYes
Walking

NoYes
Sleep
Hours/night
Sleep well

NoYes
Childhood diseases

NoneChicken PoxMeaslesMeningitisMumpsWhooping CoughRubellaOther
Has child been vaccinated?

NoYes
Any adverse reactions?

NoYes
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)

Recent Weight ChangeFeverFatigueNone in this Category
Musculoskeletal

Low Back PainMid Back PainNeck PainArm ProblemsLeg ProblemsPainful JointsStiff/Swollen JointsSore/Weak Muscles or JointsMuscle Spasms/CrampsBroken BonesNone in this CategoryOther
Neurological

Numbness or tingling sensationsLoss of FeelingDizziness or light headedFrequent or Recurrent HeadachesConvulsions or seizuresTremorsStrokeHave you ever had a head injury?Ever been in an auto accident?None in this CategoryOther
Mind/Stress

NervousnessDepressionSleep ProblemsMemory Loss or ConfusionNone in this CategoryOther
Genitourinary

Sexual DifficultyKidney StonesBurning/Painful UrinationChange in force/strain w UrinationFrequent UrinationBlood in UrineIncontinence or Bed WettingNone in this CategoryOther
Gastrointestinal

Loss of AppetiteBlood in StoolChange in Bowel MovementsPainful Bowel MovementsNausea or VomitingAbdominal PainFrequent DiarrheaConstipationNone in this CategoryOther
Cardiovascular & Heart

Chest PainsRapid or Heartbeat changesBlood Pressure ProblemsSwelling of Hands, Ankles, or FeetHeart ProblemsNone in this CategoryOther
Respiratory

Difficulty BreathingPersistent CoughCoughing BloodAsthma or WheezingLung ProblemsNone in this CategoryOther
Eyes and Vision

Wear contacts/glassesBlurred or double visionGlaucomaEye disease or injuryNone in this CategoryOther
Ears, Nose and Throat

Bleeding gums, mouth soresBad Breath or bad tasteDental ProblemsSwollen throat or voice changeSwollen glands in neckRinging in the earsEar Ache, Ringing, DrainageSinus and Allergy problemsNose BleedsHearing LossNone in this CategoryOther
Endocrine, Hematologic and Lymphatic

Thyroid problemsDiabetesExcessive Thirst or urinationCold ExtremitiesHeat or Cold intoleranceChange in hat or glove sizeDry skinGlandular or hormone problemSwollen GlandsAnemiaEasily Bruise or BleedPhlebitisTransfusionImmune system disorderNone in this CategoryOther
Skin and Breasts

Rash or itchingChange in Skin ColorChange in hair or nailsNon-healing soresChange of appearance of a moleBreast PainBreast LumpBreast DischargeNone in this CategoryOther
Women Only
Are you pregnant?

YesNo
Yes - Due Date

MonthDayYear
Date
No - Last Menstruation Period

MonthDayYear
Date
InfertilityPainful or Irregular periodsVaginal DischargeNone in this CategoryOther
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*

Clear
Date*

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Date
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