Pediatric Health History Form

CHILDREN'S HEALTH HISTORY FORM

CHILD'S PERSONAL DATA

REASON FOR SEEKING CHIROPRACTIC CARE

School
Playing
Communication
Exercise/Sports
Sleep
Eating
Walking
Attention/Focus
Daily Routine
None of the above
Other

HEALTH CARE PRACTITIONER HISTORY

Y
N
Yes
No
Rapidly improving
Improving Slowly
About the Same
Gradually Worsening
On & Off
Yes
No
Yes
No

HEALTH, VITALITY, AND CHIROPRACTIC CARE

The primary system in the body which coordinates health is the nervous system. The vertebrae bones of the spinal column, surround and protect the delicate nervous system. Injury to the spine and nervous system is a condition called a 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, CHEMICAL, & EMOTIONAL stresses your child has been through; 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.  

PREGNANCY & BIRTH

The birth process can be traumatic to a baby's spine and cause interference to the nervous system.

During pregnancy did the mother:

Y
N
Y
N
Y
N
Y
N
Y
N
Home birth
Hospital
Other
Vaginal
Water birth
Caesarean
Epidural
Foreceps
Vacuum
Pitocin
Episiotomy
Manual traction of the neck
Juandice
Feeding problem
Respiratory problems
Displaced joints
Broken bones
Other
Y
N

PHYSICAL STRESS: INFANCY & CHILDHOOD

Uncoordinated/Accident prone
Has been hospitalized
Had a servere trauma or accident
Been in an automobile accident
Has fractured a bone or dislocated a joint
Has/had a chronic illness
Has had surgery

CHEMICAL STRESS


Chemical stresses can occur when a substance that is toxic to the body is breathed, injected, ingested, or comes into contact with the skin. The following will reveal exposures your child may have experienced.

Y
N
DPT
Hepatitis
Chicken pox
Polio
MMR
Flu
None of the above
Child regularly exposed to secondhand smoke
Has taken antibiotics
Is currently taking medications
Is currently taking supplements
Has allergies

EMOTIONAL STRESS

Academic pressure
Loss of a loved one
Bullying
Relocation
Emotional Trauma
Parent's divorce
Loss of a pet
New sibling
Y
N
Y
N

OTHER

Headaches
Dizziness
Fainting
Seizures/Convulsions
Heart Trouble
Chronic Earaches
Sinus Trouble
Scoliosis
Bed Wetting
Fall in baby walker
Fall off bicycle
Fall from changing table
Orthopedic Problems
Neck Problems
Arm Problems
Leg Problems
Join Problems
Backaches
Poor Posture
Anemia
Colic
Fall from bed or couch
Fall from high chair
Fall off monkey bars
Digestive Disorders
Poor Appetite
Stomach Ache
Reflux
Constipation
Diarrhea
Hypertension
Colds/Flu
Broken Bones
Fall from crib
Fall off slide
Fall off skateboard/skates
Behavioral Problems
ADD/ADHD
Ruptures/Hernia
Growing Pains
Muscle Pain
Allergies
Asthma
Walking Trouble
Sleeping Problems
Fall off swing
Fall down stairs
None of the above

YOUR EXPECTATIONS FROM CHIROPRACTIC CARE

Symptomatic relief of a problem
Prevention of future problems
Healthier spine and nervous system
Optimal health on all levels
Other
Accept

Thank you for taking the time to fill out this form.

Serenity Health Chiropractic