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PEDIATRIC NEW PATIENT APPLICATION
Today's Date:.
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Child's Nickname:.
Child's Name:
Reason for the visit:
Gender: M / F
Age:
Date of Birth:
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Child's SS #.
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Home Address:
Home Phone:
City / State / Zip:
Who may we thank for referring you?
-City.
Pediatrician:
According to the National Safety Council, approximately 50% of infants fall head first from
(bed, changing table, etc.) during their first year of life. Has this happened to your chi
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Falls/Accidents?
Learned to walk
. months
Was a walker used?
Yes / No
.City.
Who was your prior doctor of chiropractic?,
Was your prior chiropractic doctor present during delivery?
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Yes /
No
Have you noticed any abnormality with the way your child walks or runs? (Ex: limps, high hi
or out)?
Other concerns you have?
Mother's Name
. Mother's Work.
.Cell.
Father's Name
.Father's Work_
Cell
Divorced
.Single
Married
Parent's Marital Status:
_ Widowed
Names and Ages of Other Children in Family:
Predominant Language Used at Home:
How do you wish to cover today's visit?
. Debit/Credit
Card Insurance
Check
_
Cash
Does your health insurance cover chiropractic?
Insured's: date of birth
.Other:.
Spanish
English
Yes / No
SS#
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(Please give us a copy of your i
Employer
Being the parent or legal guardian of this child, I hereby authorize this office and its d
and administer care to my son / daughter named
as the
examining / treating doctor deems necessary.
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I understand and agree that I am personally responsible for payment of all fees charged by
such care.
Parent's Name:.
Signature:.
Date:
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Witnessed by:
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CHIROPRACTIC^ AND WELLNESS CENTER
Patient Health Information Consent Form
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Today's Date
Sex:
Name
M
F
Age
Date of Birth
Reason for Today's Visit
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When did this problem first occur?
Yes
No
Yes
No
Yes
No
Have you ever had this problem before?
Have you previously been treated for this problem?
Doctor's name
When?
Have you previously been to a chiropractor?
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ABOUT YOUR HEALTH
In the past year have vou had any of the followinq
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Yes
No
Yes
No
•
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Back or neck pain?
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Pains in the legs or arms?
Headaches?
Asthma?
Allergies?
Earaches?
Falls from a bicycle, skateboard, scooter, rollerblades or similar?
Do you ever have a problem w/ith bedwetting?
Have you ever been in a motor vehicle accident?
Have you ever had any broken bones?
Have you ever had any surgeries?
Are you at present taking any medications?
Do you have any other health problems?
PAGE 1 of 2
) 2001 by Peter Fysh, D.C.
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All rights reserved.
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SCHOOL-AGE CHILD HISTORY
6 y e a r s and O l d e r
ABOUT YOUR LIFESTYLE
What grade are you in at school?
How do you carry your school books?
How heavy is your school book bag?
What sports do you play?
What hobbies do you have?
How many hours each day do you watch TV?
How many hours each day do you spend using a computer?
How often do you play video games?
On average, how many hours sleep do you get each night?
Are there any smokers in your family?
Do you feel stressed out?
Do you have trouble reading the board in class?
Do you ever have blurred vision?
Do you wear glasses or contact lenses?
Do you sometimes get headaches when you read?
ABOUT Y O U R DIET
What do you usually eat for Breakfast?
What do you usually eat for Lunch?
do you usually eat for Dinner?.
What snacks do you have after school?
What is your favorite food?
How much water do you drink each day?
How many sodas or colas do you drink each day?
How often do you eat fast food items?
PAGE 2 of 2
© 2001 by Peter Fysh, D.C.
All rights resen-ed.