Chiropractic FIRST Pediatric Registration & History Form
Patient Name: ______________________________ S.S. #:_____________________
Address: __________________________________ City: _____________________
State: _________ Zip Code: ___________ Home Phone #: ______________________
Birth Date: ___/___/____ Sex: ____ Weight: _______ Height: __________
Names of Parents/Guardians: ______________________________________________
Referred By: _______________________
In Case of Emergency Contact: _________________ Phone #: ___________________
INSURANCE
Who is responsible for this account? ___________________________
Relationship to the patient: ___________________________________
Insurance Company: ________________________________________
Subscriber ID #: _________________ Group #: __________________
Is the patient covered by additional insurance? : Yes No (circle one)
Subscriber’s Name: ___________________________________
Birth Date: ___/___/_____
S.S. #: ________________
Employer: __________________________________________
Relationship to patient: ________________________________
Insurance Company: __________________________________
Subscriber ID #: __________________
Group #: ________________________
Assignment & Release:
I, the undersigned, give authorization for care of the above named minor child. Additionally, I certify that I (or
my dependent) have insurance coverage and assign directly to Chiropractic FIRST all insurance benefits, if any, otherwise
payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by
insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize
the use if this signature on all insurance submissions.
Responsible Party Signature: ________________________________ Date: __________
PATIENT HISTORY
Previous Chiropractor: ___________________________ Date of last visit: ___________
Reason for visit: __________________________________________________________
Name of Pediatrician: ____________________________ Date of last visit: ___________
Reason for visit: __________________________________________________________
Number of doses of Antibiotics your child has taken:
During the past 6 months: ________________
Total during his/her lifetime: ______________
Vaccination History: _____________________________________________________
Circle any of the following conditions your child has suffered from:
Ear infections
Colic
Recurring Fevers
Scoliosis
Asthma/Allergies
Growing/Back Pain
Chronic Colds
Headaches
Digestive Problems
Bed Wetting
ADHD
Temper Tantrums
Other (please list): ___________________________________________________
Seizures
Auto Accident
PRENATAL HISTORY
Name of Obstetrician/Midwife: ___________________________________________
Complications during pregnancy: Yes No (circle one)
If yes, please list: ______________________________________________________
Ultrasounds during pregnancy: Yes No (circle one)
If yes, how many: ____________
Medications during pregnancy/Delivery: Yes No (circle one)
If yes, please list: _______________________________________________________
Cigarette/Alcohol use during pregnancy: Yes No (circle one)
Location of birth: Hospital
Birthing Center Home (circle one)
If other location, please list: _______________________________________________
Birth Intervention: Forceps Vacuum Extraction C-Section (circle one)
If other, please list: ______________________________________________________
Complications during Delivery: Yes No (circle one)
If yes, please list: ________________________________________________________
Genetic disorders or disabilities: Yes No (circle one)
If yes, please list: ________________________________________________________
Birth Weight: __________ Birth Length: _________ APGAR Scores _____, _______
FEEDING HISTORY
Breast Fed:
Yes No (circle one) If yes, how long: _____________
Formula Fed: Yes No (circle one) If yes, how long: _____________
Introduced to solid foods _________ months old.
Introduced to cows milk __________ months old.
Food/Juice Allergies or Intolerance Yes No (circle one) If yes, please list:___________________________
DEVELPOMENTAL HISTORY
During the following times your child’s spine is most vulnerable to stress and should
Routinely be checked by a doctor of chiropractic for prevention and early detection of vertebral subluxation (spinal nerve
interference). At what age was your child able to:
_____ Respond to sound
_____ Sit up
_____ Respond to Visual Stimuli
_____ Stand Alone
_____ Hold head up
_____ Walk Alone
_____ Cross Crawl
According to National Safety Council, approximately 50% of children fall head first from a high place during their first
year of life (i.e. a bed, changing table, stairs etc.) Was this the case with your child? Yes No (circle one)
Is/has your child been involved in any high impact or contact type sports (i.e. soccer, football, gymnastics, baseball, cheer
leading, martial arts etc.) Yes
No (circle one)
If yes, please list: ________________________________________________________
Has your child ever been involved on an auto accident? Yes No (circle one)
If yes, please list: _________________________________________________________
Has your child been seen on an emergency basis? Yes No (circle one)
If yes, please list: _________________________________________________________
Has your child had any prior surgeries? Yes No (circle one)
If yes, please list: _________________________________________________________
CHILDHOOD DISEASES
Has your child ever been diagnosed with any of the following:
Chicken Pox
Yes No (circle one) If yes, what age? _________
Mumps
Yes No (circle one) If yes, what age? _________
Rubella
Yes No (circle one) If yes, what age? _________
Rubeola
Yes No (circle one) If yes, what age? _________
Whooping Chough Yes No (circle one) If yes, what age? _________