Thank you for choosing Edmonds Family Chiropractic for your chiropractic needs. Please complete this form in ink. If you have any questions or concerns, please do not hesitate to ask for assistance. We are happy to help.
(please print clearly)
Child’s Name: _____________________________________________________________ SS/HIC/Patient ID#:________________
First Middle Initial Last
Address: ________________________________________ City: _____________________ State: _______ Zip Code: ____________
Sex: ❏ Female ❏ Male Birthdate: _____________________ Age: Years __________Months ___________
Current School: ____________________________________ Siblings Names and Ages: ___________________________________
Mother’s Name: ____________________________________ Father’s Name: ____________________________________________
Home Phone: ______________ Cell Phone: ______________ Home Phone: _______________ Cell Phone: __________________
Legal Guardian (if other than parent): ________________________________________________
Child’s Favorite Hobbies or Interests: ________________________________________________
Whom may we thank for referring you to us? __________________________________________
Name of person responsible for this account: ______________________________________________________________
Relationship to patient: _________________________________________________ Phone: ________________________
Address: ______________________________________ City: __________________ State: _______ Zip Code: ________ _
Does your Child have Health Insurance? ❏
No
❏
Yes If yes, Name of Insurance Co: _____________________________
Policy #__________________________________ Policy Holder: _________________________________________________
Please select any of the applicable reasons for pursuing chiropractic care for your child:
❏
He/she is continuing care from another chiropractor
❏
I recently had my spine checked and see the value in family subluxation check-up.
❏ I am concern about his/her health and am looking for answers.
❏
He/she has a specific condition that concerns me.
If so, please explain: __________________________________________________________________________________
❏ I have no idea why we are here. (That’s okay, we will take time to explain what we do).
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Adopted: ❏ Yes ❏ No
Delivery Information: (please check all that apply)
❏
Vaginal
❏
Forceps
❏
Vacuum Extraction
❏
Caesarean Section
❏
Breach
❏
Cord around neck
❏
Prolonged labor
❏
Drug induced labor
Any Complications during the pregnancy or with the delivery?
❏
No
❏
Yes If yes, explain: ________________________________
Has your child ever suffered from: (Check all that apply)
General Ears, Eyes, Nose, Throat Respiratory System
_
Headaches/Migraines
__ Convulsions/Epilepsy
__ Tremors
__ Loss of Balance
__ Dizziness/Vertigo
__ Fainting
__ Sleeping Problems
__ Colic
__ Cold Sweats
__ Weight Problems
__ Loss or gain of a significant
amount of weight within 6 months
__ Jaw/TMJ Problems
__ Ruptures/hernias
Serious Illnesses/Diseases
__ Chicken Pox (Age:___)
__ Measles (Age:___)
__ Mumps (Age:___)
__Rubella (Age:___)
__ Whooping Cough (Age:___)
__ Rubeola (Age:___)
__ HIV/AIDS (Age:___)
__ Cancer (Age ____, Type:______)
__ Thyroid Problems
__ Liver Trouble/Hepatitis
__ Kidney Problems
__ Diabetes Type I or II
__ Other:______________ (Age:____)
Emotional/Mental
__ Depression
__ Tension/Stress
__ Nervousness/Anxiety
__ Unexplained Fatigue
__ Behavioral Issues
__ Hyperactivity
Integumentary System
__ Skin Problems
__ Rashes
__ Skin Sensitivity
__ Easy Bruising
__ Frequent Colds/Flu
__ Blurred Vision R/L
__ Double Vision R/L
__ Ear Infection
__ Loss of Smell
__ Buzzing/Ringing in ears
__ Sinus Problems/Allergies
__ Allergies
__ Recurrent Ear Infections
__ Tooth Abscess
__ Difficulty Hearing
Musculoskeletal System
__ “Growing” Pains
__ Neck Stiffness/Pain
__ Mid-Back/Rib Stiffness/Pain
__ Low Back Stiffness/Pain
__ Hip Pain R/L
__ Fractured Bones
__ Swollen Painful Joints
__ Muscle Problems
__ Difficulty Walking
__ Scoliosis
__ Shoulder/Elbow Problems
__ Wrist/Hand Problems
__ Knee/Ankle/Foot Problems
Gastro-Intestinal System
__ Gall Bladder Problems
__ Digestive Problems
__ Stomach Upset
__ Heartburn/Reflux
__ Diarrhea/Constipation/Gas
__ Poor Appetite
__ Food Allergies or Intolerances
Genito – Urinary System
__ Recurring Infections
__ Difficulty Urinating
__ Bed Wetting
__ Asthma
__ Chronic Cough/Cold
__ Difficulty Breathing
__ Pain w/Cough/Sneeze
__ Shortness of Breath
__ Lung Problems
__ Recurring Infections
__ Sinus Problems
Nervous System
__ Numbness/Tingling/Pain in
(Arms/Hands/Fingers)
__ Numbness/Tingling/Pain in
(Buttocks/Thighs/Legs/Feet/Toes)
__ Cold Hands
Reproductive System
__Urinary Tract Infections
__ Pelvic Pain
Males Only:
__ Prostate
Females Only:
__Menstrual Cramping
__ Menstrual Irregularity
__ Vaginal Pain/Infection
__ Breast Pain/Lumps
Age of first menstrual period:
_______________________
Date of last menstrual period:
_______________________
Cardiovascular System
__ Diabetes Type I or II
__ High Blood Pressure
__ Chest Pain
__ Heart Problems
__ Anemia
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Current Habits
Please check any of the below habits that your child has:
__ Junk Food __ Health Food
__ High Level of Activity/Exercise
__ Stress __ Lack of Focus
__ Smoking __ Drinking Alcohol
__ Pop/Soda/High Sugar Fruit Drink Intake
__ Low Level of Activity/Exercise
__ Difficulty in School
__ Excessive Television/Computer/Video Game use
Medication/Supplementation
Please provide any Nutritional Supplement, Over-the-Counter Medication, or Prescription Medication taken by the child in the last year.
Please include vaccinations and antibiotics.
Supplement / Medication Name:
Amount
Taken (mg)
Frequency of administration
(___ x per__)
How long they’ve been taking it
Reason for
Supplement/Medication
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