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