PAST MEDICAL HISTORY
Your child’s birth:
Was the child’s delivery vaginal or cesarean? _______________________________________________________________
Was the child born head down, breech, or shoulder down? ____________________________________________________
Were extraction aids (Forceps/Suction) used during delivery? __________________________________________________
Was labor prolonged? ___________________ How long was labor? _____________________________________________
Y N
Has your child ever seen a chiropractor before? When? _________________________________________________
Y N
Has your child ever seen anyone else for this condition? When? __________________________________________
Y N
Allergies? To what? _____________________________________________________________________________
Y N
Does your child take prescription drugs, over-the-counter medications, vitamins, or supplements? _______________
______________________________________________________________________________________________
Y N
Has your child ever been in an automobile accident? ___________________________________________________
Was anything injured? _________________________________________________ When? ___________________
How was it treated? _____________________________________________________________________________
Results of treatment (Complete Recovery, Complications):______________________________________________
Was your child in a “booster seat”? _________________ Does your car have airbags? ________________________
Was your vehicle struck from the Rear, Front, Left Side, or Right Side? __________________________________
Y N
Has your child ever had any major illness, injuries, falls, hospitalizations or surgeries?
When? _________________________ What was injured? ______________________________________________
How was it treated? _____________________________________________________________________________
Results of treatment (Complete Recovery, Complications): ______________________________________________
Y N
Has your child had x-rays? When? _________________________________________________________________
Has your child had any problems with the
following areas? (Please mark Y for yes and N
for no in each of the following)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
___ Eyes
___ Ears, nose, mouth, throat
___ Heart
___ Lungs/breathing
___ Intestines
___ Urinary
___ Muscles
___ Nerves
___ Skin
___ Psychological
___ Internal Organs
___ Blood
___ Other _________________________
FAMILY HEALTH HISTORY
Health status (If deceased, from what?)
Mother: _________________________________________________
Father: __________________________________________________
Sisters: ______________________________ How many? _________
Brothers: ____________________________ How many? _________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
________________________________________________
____ (Initials) I acknowledge that I have received a copy of the Notice of Privacy Practices.
My signature is an acknowledgement that all of the above statements are true. I hereby authorize the doctor to examine and treat as he/she deems
appropriate through the use of chiropractic health care, and I give authority for these procedures to be performed.
GUARDIAN SIGNATURE: _________________________________________________________________________ DATE: ________________________
DOCTOR SIGNATURE: ___________________________________________________________________________ DATE: ________________________