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CHIROPRACTIC

CHILD/PEDIATRIC INTAKE

Pediatric Intake Form

Patient Information

Full Legal Name *

Date of Birth *

Gender *

Male

Female

Phone *

Email *

Address *

City *

State *

Postal code *

Person Completing This Form *

Your Relationship To Patient *

Emergency Contact Name *

Emergency Contact Phone Number *

Pediatrician Name *

Pediatrician Phone Number *

Date *

Initial Problem Record

What is your main complaint or problem? *

When did this begin? *

What have you tried, to help treat your child and this problem?

How severe is this problem?

Mild
Moderate
Severe
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Complaint #2

Complaint #2 - When did this begin?

Complaint #2 - What have you tried, to help your child with this problem?

Compaint #2 - How severe is the problem?

Mild
Moderate
Severe
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Medical History and Present Medical Condition Questionnaire

Does your child have any problems with the following? Check all that apply: *

Lethargic

Poor Weight Gain

Sensitivity to Light

Neck Pain

Difficulty Concentrating

Easy Bruising

Colic

Pale Stool

Poor appetite

Short of Breath

Fainting Spells

Heavy/Painful Menses

Trauma

Joint Swelling

Seasonal allergies

Anxiety

Failure to thrive

Poor Vision

Ear Pain

Sore Throat

Seasonal Allergies

Headaches

Abdominal Pain

Constipation

Food Sensitivities

Excessive thirst

Wheezing

Heart Murmur

Painful Urination

Testicular Pain/Swelling

Skin Rash

Swollen glands

Depressed Mood

Fevers

Pink Eye

Nosebleed

Developmental Delay

Academic Problems

Bloody/Black Stool

Diarrhea

Frequent Spit Ups/Vomiting

Cough

Chest Pain

Bed Wetting after age 4

Poor Muscle Tone

Joint/Muscle Pain

Frequent Infections

Swollen Hands/Feet

None of the above

Has your child had or does your child currently have any of the following:

Anxiety

Yes

No

Currently

Asthma

Yes

No

Currently

ADHD

Yes

No

Currently

Bleeding Disorder

Yes

No

Currently

Bowel disease

Yes

No

Currently

Cancer

Yes

No

Currently

Chronic Pain

Yes

No

Currently

Depression

Yes

No

Currently

Diabetes

Yes

No

Currently

Eye Disease

Yes

No

Currently

Eye Infections

Yes

No

Currently

Ear Infections

Yes

No

Currently

Heart Disease

Yes

No

Currently

Kidney Disease

Yes

No

Currently

Liver Disease

Yes

No

Currently

Physical Abuse

Yes

No

Currently

Sexual Abuse

Yes

No

Currently

Seizures/Multiple

Yes

No

Currently

Thyroid Problems

Yes

No

Currently

Urine Infections

Yes

No

Currently

Other:

Birth History

Age (weeks) at delivery *

Prolonged Hospital Stays? Please explain below. If none, enter 'N/A'

Delivery Type *

Vaginal

C-section

Complications

Issues during pregnancy *

Infertility

Drug Use

No Prenatal Care

Gestational DM

Pre-eclampsia/Eclampsia

Abnormal Ultrasound

Prenatal Infection

Other

None

Milestones

Please check all your child has met:

Rolling Over

Sitting Up

Standing

Walking

Talking

Potty Trained

Concerns about milestones/age child hit milestone(s)/milestone(s) not hit yet?

Complications during first month of child's life?

Yes
No
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If yes; please describe:

Concerns about developmental delays? *

Yes
No
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If yes; age of onset:

Surgical History & Medications

Has child ever been hospitalized? *

Yes
No
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If yes; please list reason and approximate month & year

Surgical History *

Appendectomy

Circumcision

Hernia

Tonsillectomy

Ear Tubes

Other

None

Has your child been on antibiotics in the last 6 months? *

Yes
No
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Is your child taking any medications? *

Yes
No
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List all medications, including over the counter medications:

Does your child have any allergies? *

Yes
No
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Is yes, please list all known allergies & reactions:

Signature *

Clear

Captcha

Brain, Not Bone Alone

Get in Touch

Phone: (970) 622-0075

Business Hours

Monday: 2pm-6pm

Tuesday: 8am-12pm, 2pm-6pm

Wednesday: 8am-12pm, 2pm-6pm

Thursday: 2pm-6pm

Friday: By special appointment only

Location:

2216 Hoffman Drive, Unit A,

Loveland, CO 80538

2216 Hoffman Dr unit a, Loveland, CO 80538, USA