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

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

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

Area CodePhone Number
Who referred you to our office?
If referred by friend, family or your physician, please provide their name:
Please provide a contact in case of emergency

First NameLast Name
Emergency contact phone number

Area CodePhone Number
Primary care physician

First NameLast Name
Primary care physician phone number

Area CodePhone 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

Other
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)
Please list your relationship to the insured
Provider services phone number (usually listed on the back of the ID card)

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

First NameLast Name
Policy holder's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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?
Is your child 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?
What was the frequency?
Place of Birth:
Provider:

Other
Type of Birth:
Were pain medications used?
Was labor induced?
What position did you deliver in?

Other
Birthing Trauma

Other
APGAR Score:
Did your child have a misshaped skull/head
Were there purple marks on their face?
Did/do you breastfeed your child?
Does your child prefer one breast over the other?
If yes, which side?
Does your child have any food allergies?
If yes, please list:
Has your child been immunized?
Did your child have any negative reactions to the vaccinations, and if so were they reported?
Has your child had any surgeries?
If yes, please elaborate:
Has your child had either of these procedures?
Has your child been on antibiotics?
If yes, how often and what for?
Is your child currently taking any medications?
If yes, how often and what for?
Is your child currently taking any vitamins?
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?
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?

Other
Primary Health Complaint:
When did it begin?
Has it affected the child's activity?
Please list all sports activities your child is involved in:
How would you rate your child's diet?
Does your child consume artificial sweeteners?
Does your child consume fluorinated water?
On average how many hours of sleep does your child get?
How is the quality of their sleep?
By signing below I agree to above and am authorizing examination and care for the dependent listed on this form.
HIPAA Privacy Practices Below
I have reviewed the HIPAA Privacy Practices for Gard Wellness Center (above)
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)