Please Fill Out the Pediatric Patient Questionnaire Below:

    Confidential Patient Information

    Has your child ever received health care from any other professionals?

    -If Yes, please explain:

    Current Health Conditions

    How did the problem start?

    Is this condition:

    Has your child ever received care for this condition before?

    -If Yes, please explain:

    Health Goals For Your Child

    What would you like to gain from your chiropractic care?

    Have you ever visited a chiropractor?

    -If Yes, what is their name?

    What is their specialty?

    Pregnancy and Fertility History

    Tell us about your pregnancy

    Any fertility issues?

    -If yes, please explain:

    Did mother smoke?

    -If yes, how many per week?

    Did mother drink?

    -If yes, how many per week?

    Did mother exercise?

    -If yes, please explain:

    Was mother ill?

    -If yes, please explain:

    Any ultrasounds?

    -If yes, please explain:

    Labor and Delivery History

    Child's birth was:

    At how many weeks was your child born?

    Birth was:

    -If other, where:

    Doctor or Obstetrician's Name:

    Please check any applicable interventions or complications:

    -If other, please explain:

    Child's birth weight/lbs and oz:

    Child's birth height/inches:

    APGAR score at birth:

    APGAR score after 5 minutes:

    Growth and Development History

    Was your child breastfed?

    -If yes, how long?

    Difficulty with breastfeeding?

    Did they ever use formula?

    -If yes, at what age?

    -If yes, what type?

    Does/did your child suffer from colic, reflux, or constipation as an infant?

    -If yes, please explain:

    Does/did your child frequently arch their neck/back, feel stiff, or band their head?

    -If yes, please explain:

    At what age did your child:

    Have you chosen to vaccinate your child?

    -If yes, please list any vaccination reactions:

    Has your child received any antibiotics?

    -If yes, how many times and list reason:

    Night terrors or difficulty sleeping?

    -If yes, please explain:

    Behavioral, social or emotional issues?

    -If yes, please explain:

    How would you describe your child's diet?

    Acknowledgement & Consent