Pediatric Intake Form

PEDIATRIC HISTORY FORM

PATIENT DEMOGRAPHICS

CHILD'S CURRENT PROBLEM:

Wellness Check-up
Injury or accident
Other
Yes
No
Days
Weeks
Months
Years
Rapidly improving
Improving Slowly
About the Same
Gradually Worsening
On & Off
Headaches
Dizziness
Fainting
Seizures/Convulsions
Heart Trouble
Chronic Earaches
Sinus Trouble
Scoliosis
Bed Wetting
Fall in baby walker
Fall off bicycle
Fall from changing table
Orthopedic Problems
Neck Problems
Arm Problems
Leg Problems
Join Problems
Backaches
Poor Posture
Anemia
Colic
Fall from bed or couch
Fall from high chair
Fall off monkey bars
Digestive Disorders
Poor Appetite
Stomach Ache
Reflux
Constipation
Diarrhea
Hypertension
Colds/Flu
Broken Bones
Fall from crib
Fall off slide
Fall off skateboard/skates
Behavioral Problems
ADD/ADHD
Ruptures/Hernia
Growing Pains
Muscle Pain
Allergies
Asthma
Walking Trouble
Sleeping Problems
Fall off swing
Fall down stairs
Other

I understand that I am directly and fully responsible to this office for all fees associated with chiropractic care my child receives.

The risks associated with exposure to x-rays and spinal adjustments have been explained to me to my complete satisfaction, and I have

conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request and authorize imaging studies and

chiropractic adjustments for the benefit of my minor child for whom I have the legal right to select and authorize health care services on

behalf of. I hereby request and authorize this office to administer healthcare as deemed necessary to my dependent minor child. This

authorization also extends to include diagnostic imaging, laboratory and other testing at the doctor’s discretion.

Accept

Activities of Daily Living/Symptoms/Medications 

Daily Activities: Effects of Current Conditions on Performance:

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

No Effect
Painful(can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Preform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (Can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
No Effect
Painful (can do)
Painful (limits)
Unable to Perform

For Office Use Only

I have reviewed the above ADL & ROS form with the above named patient:

Thank you for taking the time to fill out this form.

Contact Us

Questions, Comments, Concerns - all are welcome.

Our Location

950 Yale Ave, Suite 29. Wallingford, CT 06492

Office Hours

Open Monday through Thursday

Monday:

9:00 am-11:00 AM

3:00 pm-6:00 pm

Tuesday:

3:00 pm-6:00 pm

Wednesday:

9:00 am-11:00 AM

3:00 pm-6:00 pm

Thursday:

8:15 am-10:45 am

Friday:

By Appointment Only

Saturday:

By Appointment Only

Sunday:

Closed