Pediatric Patient Form

Abundant Health Family Chiropractic, Bozeman, MT

Please complete this form in its entirety. ALL INFORMATION IS KEPT CONFIDENTIAL.

Patient Information:

First Name Last Name Address City

State

Zip Code

Home Phone

Date of Birth

Last 4 Digits of SSN

Height

Weight

Sex Male Female

Name of Parent or Guardian

Work Phone

General Information:

If referred to my office, by whom?

Purpose of visit/ specific concern:

Has your child seen other Doctors for this condition?

Yes No

Doctor's Name:

Treatment:

Has your child ever been to a chiropractor before?

Yes No

Chiropractor's Name

When was the last visit?

Reason for Care:

Does your child have other Health Problems?

Yes No

Please Describe:

Name of Pediatrician:

Date of Last Visit:

Number of Doses of Antibiotics your child has taken:

Last 6 Months

Lifetime

Number of Doses of Prescription Medication
your child has taken:

Last 6 Months

Lifetime

Vaccination History:

Prenatal History:

Name of Obstetrician/ Midwife:

Complications During Pregnancy?

Yes No

List:

Complications During Delivery?

Yes No

List:

Ultrasounds During Pregnancy?

Yes No

How Many?

Medications During Pregnancy?

Yes No

List:

Cigarettes/ Alcohol use During Pregnancy?

Yes No

Please Describe:

Location of Birth:

Hospital Birthing Center Home

Birth Intervention:

Forceps Vacuum Extraction C-Section

Birth Height:

Birth Weight:

Feeding History:

Breastfed?

Yes No

How Long?

Formula fed?

Yes No

How Long?

Introduced Solids at:

months

Introduced Cows Milk at:

months

Food/ Juice Allergies or Intolerances?

Yes No

List:

Developmental History:

During the following times your child's spine is most vulnerable to stress and should routinely be checked by a doctor of chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference). At what age was your child able to:

Respond to Sound

Hold Head Up

Cross Crawl

Stand Alone

Sit Up

Respond to Visual Stimuli

Walk Alone

According to the National Safety Council, approximately 50% of children fall from a high place during their first year of life (e.g. a bed, changing table, down stairs etc). Was this the case with you child?

Yes No

Please Describe:

Is/ Has your child been involved in any high impact or contact type sports (i.e. soccer, football, gymnastics, baseball, cheerleading, martial arts, etc.)?

Yes No

List:

Has your child ever been involved in a car accident?

Yes No

Please Describe:

Has your child been seen on an emergency basis?

Yes No

Reason:

Other traumas not described above?

Yes No

Please Describe:

Prior Surgery?

Yes No

List:

Menarche?

Yes No

Age:

Consent to Treat a Minor:

I hereby request and authorize this office and its doctor to perform diagnostic test and render chiropractic care as she deems necessary, to my minor child: .

As of this date, I have the legal right to select and authorize health care services for the minor child named above.

Parent or Guardian Print Name

Date

If you have questions, or if for any reason you would rather us send you forms through mail or email, don't hesitate to call us at:

Bozeman Office: 406.585.7000
or email us at info@AbundantHealthFamilyChiro.com