PEDIATRIC PATIENT APPLICATION FOR CARE
CHILD’S NAME: ______________________________ MOTHER’S NAME:
LAST
FIRST
MIDDLE
LAST
FIRST
MIDDLE
LAST
FIRST
MIDDLE
FATHER’S NAME:
CASE NUMBER:
ADDRESS: _______________________________ CITY/TOWN: ________________ STATE: _____ ZIP:
HOME PHONE: ____________ MOTHER’S WORK PHONE: ____________ FATHER’S WORK PHONE:
BIRTH DATE: ____/____/____ AGE: ____ BIRTH WEIGHT: _________________ CURRENT WEIGHT:
SEX: _________ NO. OF SIBLINGS: __________ BIRTH LENGTH: __________ CURRENT LENGTH:
TYPE OF BIRTH:
NORMAL VAGINAL _______
HOME: ____________
FORCEPS _______
BREECH _______
BIRTHING CENTER: ____________
CESAREAN
HOSPITAL:
PROBLEMS DURING
PREGNANCY:
PROBLEMS DURING
LABOR/DELIVERY:
APGAR SCORES: __________________
WAS THERE PRESENCE AT BIRTH OF: _____ JAUNDICE (YELLOW)
_____ CYANOSIS (BLUE)
CONGENITAL ANOMALIES/DEFECTS:
INFANT FEEDING:
BREAST __________
BOTTLE __________
NO. OF HOURS OF SLEEP PER NIGHT: ________
FORMULA: ___________
QUALITY OF SLEEP: GOOD _____ FAIR _____ POOR
OBSTETRICIAN/MIDWIFE:
NAME
LOCATED AT
NAME
LOCATED AT
PEDIATRICIAN/FAMILY MD:
DATE OF LAST VISIT TO MD: _____________________ PURPOSE:
IMMUNIZATION HISTORY:
PURPOSE OF THIS APPOINTMENT:
HAS YOUR CHILD BEEN TREATED ON AN EMERGENCY BASIS?:
DESCRIBE:
AUTHORIZATION FOR CARE OF MINOR
I HEREBY AUTHORIZE WESTWOOD FAMILY CHIROPRACTIC, LLC. AND IT’S DOCTOR(S) TO PROVIDE CARE AS
THEY SO DEEM NECESSARY TO MY SON/DAUGHTER/WARD.
SIGNED: ________________________ WITNESSED: __________________________ DATE:
I REALIZE THAT I AM RESPONSIBLE FOR ALL FEES CHARGED BY THIS OFFICE AND THAT I WILL PAY FOR
ALL SERVICES AS THEY ARE PERFORMED. X-RAYS REMAIN THE PROPERTY OF THIS OFFICE.
DATE: _________________ SIGNATURE:
PEDIATRIC CASE HISTORY
PREGNANCY HISTORY:
DELIVERY/BIRTH HISTORY:
DEVELOPMENTAL HISTORY: AT WHAT AGE DID THE CHILD…
____________ RESPOND TO SOUND
____________ FOLLOW AN OBJECT WITH HIS/HER EYES
____________ HOLD HEAD UP
____________ SIT ALONE
CHILDHOOD DISEASES: ____________ CHICKENPOX
____________ MUMPS
____________ MEASLES
OTHER:
HAS THIS CHILD EVER SUFFERED FROM:
 Dizziness
 Backaches
 Diabetes
 Tuberculosis
 Arthritis
 Headaches
 Neuritis
 Digestive Disorders
 Anemia
 Rheumatic Fever
 Poor Appetite
 Hyperactivity
 Bed Wetting
 Convulsions
 Fainting
 Walking Problems
 Neck Problems
 Arm Problems
 Joint Problems
PRESENT HISTORY:
SURGERY:
MEDICATIONS:
ACCIDENTS:
FAMILY HISTORY:
____________ CRAWL
____________ STAND
____________ WALK ALONE
____________ RUBELLA
____________ RUBEOLA
____________ WHOOPING COUGH
 Heart Trouble
 Hypertension
 Asthma
 Sinus Trouble
 Orthopedic Problems
 Sugar Concentration
 Paralysis
 Broken Bones
 Leg Problems
 Chronic Earaches
 Colds/Flu
 Allergies
 Constipation
 Diarrhea
 Behavioral Problems
 Muscle Jerking
 Ruptures/Hernias
 “Growing Pains”
Westwood Family Chiropractic
99 Kinderkamack Road
Westwood NJ 07675
Electronic Health Records Intake Form
In compliance with requirements for the government EHR incentive program
CMS requires providers to report both race and ethnicity
- First Name:_________________________
Last Name:_________________________
- Email address: _________________@_________________
DOB: __/__/____
- Preferred Language: __________________ Gender (Circle one): Male / Female
- Smoking Status (Check one):
___Every Day Smoker
___Occasional Smoker
___Former Smoker
___Never Smoked
-Height: ____’ ____’’
Weight:___________ Blood Pressure:______ /______
- Race (Check one):
___American Indian or Alaska Native
___Asian
___Black or African American
___White (Caucasian)
___Native Hawaiian or Pacific Islander
___Other
___I Decline to Answer
-Ethnicity (Check one):
___Hispanic or Latino
___Not Hispanic or Latino
___I Decline to Answer
- Are you currently taking any medications? (Please include regularly used over the counter medications)
Medication Name
Dosage and Frequency (i.e. 5mg once a day, etc.)
- Do you have any medication allergies?
Medication Name
Reaction
Onset Date
Additional Comments
□ I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a
result of the nature and frequency of chiropractic care.)
Patient Signature: _____________________________________________
Date:________________
WFC NOTICE OF PRIVACY PRACTICES
By my signature or guardian signature I have read the Privacy Notice
and authorization for appointment reminders, scheduling, and contact
and understand my rights contained in the notice.
_________________________________
Patient Name ( please print)
_______________________________________
Patient/Guardian Signature
________________________________________
Authorized Westwood Family Chiropractic,LLC Staff Signature
___________________
Date