Pediatric Health Story Form Child s Personal Information Name Age Date of Birth Gender: M F Home Address City State Zip Names and Ages of Siblings Parent A Name Home phone ( ) Cell phone ( ) Employer E-mail Is it okay if we contact you at work? Yes No Parent B Name Home phone ( ) Cell phone ( ) Employer E-mail Is it okay if we contact you at work? Yes No Parent A B Social Security # - - Whom may we thank for referring you to our office? Health Care Practitioner History Has your child ever received chiropractic care? Yes No Name of D.C. Reason How long? Date of last visit Why was care stopped? Were you pleased with care? Yes No Please explain Have you consulted or do you regularly consult any of the following providers for your child? Check all that apply Naturopath Acupuncturist Homeopath Massage Therapist Psychotherapist Energy Healer Other Reason Does your child have a pediatrician? Yes No If so, what is the doctor s name? Date of last visit Page 1
Reason for Seeking Chiropractic Care What concerns do you feel Pure Light Family Chiropractic can address for your child? Please indicate below how these concerns are affecting your child s uality of life. (Check all that apply) School Exercise/Sports Walking Playing Sleep Attention/Focus Communication Eating Daily Routine Other When did this condition first begin? How did the condition start? Suddenly Gradually Post-Injury Is this condition Getting Worse Improving Intermittent Constant Unsure What makes the condition better? What makes the condition worse? Has your child ever had a similar condition? Yes No Please explain Has your child received care for this condition before? Yes No Please explain Check any of the following conditions your child has suffered from during the past six months: Sleeping Problems Fainting Vision Changes Light Sensitivity Irritability Dental problems Loss of Balance Poor Coordination Ear Infections Temper Tantrums Scoliosis Seizures Asthma Digestive Problems ADHD Recurring Fevers Growing Pains Colic Bed Wetting Car Accident Allergies Other Growth and Development Child s birth weight Child s birth length Current weight Current height APGAR score at birth APGAR score after 5 minutes Was your child alert and responsive within 12 hours of delivery? Yes No If no, please explain Does your child have any genetic disorder or disabilities? Yes No If yes, please explain Page 2
During growth and development your child s spine is vulnerable to stress and should routinely be checked by a pediatric chiropractor for prevention and early detection of vertebral subluxations (spinal nerve interference). At what age did your child: Respond to sound Follow an object Hold head up Vocalize Sit alone Teethe Cross crawl Stand alone Walk Is/was your child breastfed? Yes No If yes, how long? Formula introduced at age What type? Introduction of cow s milk at age Began solids at age Please list any foods/juice intolerance If breastfed, any difficulty with breastfeeding? Yes No N/A If yes please explain Any difficulty with bonding? Yes No If yes, please explain Any behavioral problems? Yes No If yes, please explain Any night terrors, sleep walking or difficulty sleeping? Yes No If yes, please explain Injury and Medical History According to the National Safety Council, approximately 50% of children fall head first from a high place during their first year of life (i.e. bed, changing table, down stairs, etc.). Was this the case for your child? Yes No Has your child ever been involved in a car accident? Yes No If yes, please explain 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 If yes, please explain Please list any major injuries, accidents, falls and/or fractures your child has had in his/her lifetime, including this year In/Out-Patient/Hospitalization/Surgical history (please list below all surgeries and hospitalizations, including this year) Childhood Infections Chicken Pox Age Mumps Age Rubella Age Pertussis Age Rubeola Age Other Age Page 3
Health, Wellness and Chiropractic Care The primary system in your and your child s body which coordinates health is the NERVE SYSTEM. The vertebrae (bones of the spinal column) surround and protect the delicate NERVE SYSTEM. Injury to the SPINE and NERVE SYSTEM is a condition called vertebral subluxation. Vertebral subluxation results in nerve malfunction due to vertebral/spinal misalignment. Vertebral subluxations can have Physical - Emotional - and Chemical causes and effects. The information below helps the chiropractor see the types of PHYSICAL, EMOTIONAL & CHEMICAL stresses your child has been subjected to; how they may relate to his/her present spinal, nerve and health status and whether they may have played a part in creating vertebral subluxations. Physical Stress: Pregnancy & Birth Our Obstetrician Midwife Family Physician was During pregnancy, did you/the mother: Experience any significant illnesses, difficulties, or trauma? Yes No If yes, please explain Take any drugs/medications/supplements? Yes No If yes, please explain Smoke or consume alcohol? Yes No Any exposure to ultrasound? Yes No If yes, how many and what was the medical reason? Was the delivery premature? Yes No Weeks Weight Approximately how long did labor last? hours Was labor artificially induced? Yes No If yes, please explain Was your child in a breech position or otherwise malpositioned? Yes No If yes, please explain Page 4
The birth process can be traumatic to your baby s spine and cause interference to the nerve system. Please check where/how your baby was born and if any of the following were administered during labor and birth. Home birth Hospital birth Birthing Center Vaginal Water birth Scheduled Caesarean Emergency Caesarean Epidural Forceps Vacuum Episiotomy Cord around neck Manual traction of the neck Medications Other Please check all that apply to your baby s status immediately after birth: APGAR Score / Jaundice Respiratory problems Feeding problem Displaced joints Odd shaped head Broken bones Other conditions Following delivery, was your baby breastfed? Yes No If so, for how long? Physical Stress: Infancy & Childhood Please check all that apply to your child and give any necessary details: Uncoordinated/Accident prone Has been hospitalized Had a severe trauma Been in an automobile accident Has fractured a bone or dislocated a joint Has/had a chronic illness Has had surgery What physical activities does your child participate in? Is a school backpack used? Yes No If yes, is it Heavy Light Chemical Stress Chemical stresses can occur when a substance that is toxic to the body is breathed, injected, taken by mouth, or contacts the skin. The following will reveal exposures your child may have experienced. Please check all that apply and give any necessary details: Child exposed to second hand smoke. Has taken antibiotics. Explain Currently taking medication. Explain Currently taking supplements/vitamins/herbs/homeopathics. Explain Has allergies. Explain What treatments have you used? Page 5
Have you chosen to vaccinate your child? Yes No If yes, please check all vaccinations your child has received. On the blank line, please state at what age they were administered: Hepatitis DPT MMR Chicken Pox Flu Other Please describe any and all reactions to vaccine(s) Does your child eat well? Yes No Does your child have regular bowel/bladder movements? Yes No Emotional Stress It can be difficult to separate the emotional stress in our life from the physical response that often occurs. Please indicate if your child has ever or is currently experiencing any of the emotional stresses below: (check all that apply) Academic pressure Loss of a loved one Bullying Relocation Lifestyle change Parents divorce Loss of a pet New sibling Does your child have difficulty interacting with schoolmates or friends? Yes No Have you or anyone else noticed that your child is nervous, twitches, shakes, or exhibits rocking behavior? Yes No Age of your child when she/he began daycare? Average number of hours of TV/computer/iPad/technology per week? Do you feel that your child s social and emotional development is normal for their age? Yes No If no, please explain Are there any other health concerns or anything else you d like us to know about your child? N/A Expectations of Care I would like my child to experience the following benefits from Chiropractic Care: Check all that apply Symptomatic relief of a problem Correction of the cause of a problem as well as relief. Prevention of future problems Healthier spine and nerve system Optimal health on all levels Other Thank you for choosing Pure Light Family Chiropractic. We look forward to doing an evaluation and determining how we can help your child. Page 6
Terms of Acceptance When a person seeks chiropractic health care and we accept a person for such care, it is essential for both parties to be working towards the same objective. Chiropractic has only one goal. It is important that each person understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of your child s chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our only practice objective is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. I, have read and fully understand the above statements. (print name) All uestions regarding the doctor s objectives pertaining to my care in this office have been or will be answered to my complete satisfaction. I therefore accept chiropractic care for my child on this basis. Child s Name: (Printed) Parent or Legal Guardian s Name: (Printed) Signature Date: Page 1
Consent to Care I do hereby authorize the doctor(s) of Pure Light Family Chiropractic to administer chiropractic care that is necessary for my child s particular case. This may include consultation, examination, adjustments or any other procedure which is advisable and necessary for my child s health care. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not. I understand that payment for care is out-of-pocket and paid before or directly after services are rendered. If I wish to obtain reimbursement from my health insurance company, Pure Light Family Chiropractic will supply the proper documentation necessary to receive reimbursement for services. Pure Light Family Chiropractic is not liable for any lack of reimbursement from my health insurance company. I have read, understand and hereby reuest chiropractic care for my child based on the terms of acceptance and the consent to care. Child s Name: (Printed) Parent or Legal Guardian s Name: (Printed) Signature Date: Page 2