PEDIATRIC HISTORY FORM
PATIENT DEMOGRAPHICS
HR#: ______________________
Childs Name__________________________________________________ Today's Date _____/_____/____
Date of Birth _____/_____/______ Birth Height: _______ Birth Weight: _______ Current Height: _______
Current Weight: _____ Age: _____ Address ________________________________________________________
City _____________________ State _______ Zip ___________________ Phone (Home) _____________________
Mothers Name ____________________________
Mother’s Mobile __________________________
DOB____/____/____
Fathers Name ____________________________
Father’s Mobile ___________________________
DOB ____/____/____
Pediatrician/Family MD _____________________________________
City & State ___________________________
Last Visit ____/____/____
Reason for Visit __________________________________________________________
Who is responsible for this bill? ___________________________________________________________________
 Child’s Social Security Number _________________________________________________________________
 Other (please explain):
Purpose of this visit:
_____Wellness Check-up _____Injury or Accident _____Other
Please explain: __________________________________
If your child is experiencing Pain/Discomfort please identify where and for how long
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Who is your pediatrician? ________________________________________________________________________
Please describe and date the following:
1.
Type of birth? Natural or C-Section? Were any of the following used: forceps/clamps, epidural, other? How
long was labor?
_____________________________________________________________________________________________
2. Any history of trauma or falls?
_____________________________________________________________________________________________
3. Has your child ever been vaccinated and if so when was the last vaccination?
_____________________________________________________________________________________________
4. Has your child had any antibiotics? How often? Any other prescriptions? Please list (on back if necessary)
_____________________________________________________________________________________________
5. Has your child had any surgeries?
_____________________________________________________________________________________________
Thank you for providing us this information.
What is the ultimate outcome/goal in bringing your child to our office?
_____________________________________________________________________________________________
 I understand that I am fully responsible for payment at time of service to Northern Lights Chiropractic for all
fees associated with chiropractic care my child receives. If money is a concern, I know that NLC has many
affordable payment options for me.
 I understand that I am responsible for the Child Exam fee of $35
 I understand that I am responsible for the Child Adjustment fee of $25
 Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a
spouse/former spouse or other guardian is not required. If my authority to so select and authorize this care should
change in any way, I will immediately notify this office.
____________________________________________
Parent or Legal Guardian’s Signature
____________________
Date
____________________________________________
Doctor Signature
____________________
Date
JDD,DC 5/2011