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First Name
Last Name
Address
City
Zip/Postal Code
State/Prov
Gender
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?


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Complications during pregnancy?
Ultrasounds during pregnancy?
Medications during pregnancy?
Cigarette/alcohol use during pregnancy?
Location of birth:
Birth intervention performed:
Delivery medication?
Delivery complications?
Birth Weight
APGAR Scores
Birth Length


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Name of Pediatrician
Date of Last Visit
Reason
Treatment
At what age, in months, was the following introduced?
Solids:
Cows milk:
At what age was your child able to (in months):
Respond to sound
Hold head up
Crawl
Sit



Respond to visual stimuli
Stand Alone
Walk Alone


Personal Illness History


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Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases


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Number of doses of antibiotics your child has taken:
Last 6 months: Since birth:
Number of doses of other prescription medications your child has taken:
Last 6 months: Since birth:
Child's daily habits (skip any questions that do not apply):
Hours of sleep per night (1-24)
Child's exercise
Average amount of time spent watching TV, playing video games, or using a computer per day:
How often does this child consume:
Caffeine Drinks:
Sugars/sweets:
Dairy Products
Wheat Products
Fruits/Vegetables
Water as a beverage:



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Present problem:
First occurrence of condition
Did something specific cause this condition? (please describe)
Since the problem started, is it:
Does anything make it better?
Does anything make it worse?
Other health professionals seen for this problem (please list names and dates if applicable)
Chiropractor
Medical Doctor
Other


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