Pediatric Intake

New Chiropractic Pediatric Intake

Please complete this form prior at least 24 hours prior to your appointment. Feel free to call if you have problems with this form 919-322-4383. We look forward to seeing you soon!
Name *

First Name Last Name
If the patient's preferred name is different than your given name, please enter below:
Please enter the patient's date of birth *

Month Day Year
Please enter the patient's social security number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Who referred you to our office? *

a friend my doctor Google/internet search my health insurance
If referred by friend, family or your physician, please provide their name:
Please provide a contact in case of emergency *

First Name Last Name
Emergency contact phone number *

Area Code Phone Number
Primary care physician

First Name Last Name
Primary care physician phone number

Area Code Phone Number
Health insurance policy information

Please complete this section entirely. If you are self pay (do not participate with a health insurance plan) please select self pay and move to the next section.
Please select the name of your health insurance provider *

Blue Cross Blue Shield Cigna Medcost United Healthcare Aetna Medicare Self-pay/Cash
Subscriber ID / Member ID
This is generally listed on the front of your insurance ID card and may be alpha numeric. Please include all characters listed including any listed suffix (01,02,03, etc)
Group number
Please list your relationship to the insured

I am the policy holder My spouse is the policy holder I am a dependent of the policy holder
Provider services phone number (usually listed on the back of the ID card)

Area Code Phone Number
If you are not the policy holder, please enter the policy holder's name

First Name Last Name
Policy holder's date of birth

Month Day Year
Date
Prenatal History

Please complete the following fields to the best of your ability. This information will help us with your case and should not be left blank.
Is your child adopted? *

Yes No Unknown
Is your child under routine care? *

Under routine care with no complications Under routine care with complications Not under routine care
Birth History

Please complete the following fields to the best of your ability. This information will help us with your case and should not be left blank.
Did you have ultrasound during pregnancy? *

No Yes
What was the frequency?
Place of Birth: *

Home Birthing Center Hospital
Provider:

Midwife OB-Gyn
Type of Birth: *

Vaginal C-Section
Were pain medications used? *

Yes No
Was labor induced? *

Yes No
What position did you deliver in?

Squatting On back
Birthing Trauma

Doctor assisted Twisting/Pulling Vacuum Extraction Forceps
APGAR Score:
Did your child have a misshaped skull/head

Yes No
Were there purple marks on their face?

Yes No
Did/do you breastfeed your child?

Yes No
Does your child prefer one breast over the other?

Yes No
If yes, which side?
Does your child have any food allergies? *

Yes No
If yes, please list:
Has your child been immunized? *

Not yet Fully vaccinated according to CDC schedule On modified vaccination schedule
Did your child have any negative reactions to the vaccinations, and if so were they reported? *

No reactions Had a reaction and reported it Had a reaction and did not report it
Has your child had any surgeries? *

Yes No
If yes, please elaborate:
Has your child had either of these procedures?

Tongue Tie Lip Tie
Has your child been on antibiotics?

Yes No
If yes, how often and what for?
Is your child currently taking any medications? *

Yes No
If yes, how often and what for?
Is your child currently taking any vitamins? *

Yes No
If yes, how often and what for?
Baby/Toddler (0-4)

Please complete the following fields to the best of your ability if your child is within this age range. This information will help us with your case and should not be left blank.
Have any of the following occurred?

Fall from a changing table Fall out of a crib Tonsillitis Constipation Frequent crying spells Fall off of playground equipment Sleeping problems Tumble down stairs Frequent fevers Repeated infections or colds Involvement in MVA Frequent ear infections Frequent diarrhea Colic
Child (5-12)

Please complete the following fields to the best of your ability if your child is within this age range. This information will help us with your case and should not be left blank.
Have any of the following occurred?

Fall from a tree Stomach pains Hyperactivity/Autism Leg/knee pains Fall off of a bicycle Scoliosis Learning difficulties Sports accident Bed wetting Asthma Involvement in MVA Fall on playground Allergies
Primary Health Complaint:
When did it begin?
Has it affected the child's activity?

Yes No
Please list all sports activities your child is involved in:
How would you rate your child's diet?

Well balanced Average High sugar/processed foods
Does your child consume artificial sweeteners?

Yes No
Does your child consume fluoridated water?

Yes No Not sure
On average how many hours of sleep does your child get?
How is the quality of their sleep?

Good Fair Poor
By signing below I agree to above and am authorizing examination and care for the dependent listed on this form. *

Clear
HIPAA Privacy Practices Below
I have reviewed the HIPAA Privacy Practices for Gard Wellness Center (above) *

Clear
You're done! Thank you for completing this form, click 'Submit' below and we'll receive your information. We look forward to helping you life life well!
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New Chiropractic Pediatric Intake

Health insurance policy information

Prenatal History

Birth History

Baby/Toddler (0-4)

Child (5-12)