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
Please enter the patient's social security number*
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?*

a friendmy doctorGoogle/internet searchmy health insurance
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*

Blue Cross Blue ShieldCignaMedcostUnited HealthcareAetnaMedicareSelf-pay/CashOther
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 holderMy spouse is the policy holderI am a dependent of the policy holder
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
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?*

YesNoUnknown
Is your child under routine care?*

Under routine care with no complicationsUnder routine care with complicationsNot 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?*

NoYes
What was the frequency?
Place of Birth:*

HomeBirthing CenterHospital
Provider:

MidwifeOB-GynOther
Type of Birth:*

VaginalC-Section
Were pain medications used?*

YesNo
Was labor induced?*

YesNo
What position did you deliver in?

SquattingOn backOther
Birthing Trauma

Doctor assistedTwisting/PullingVacuum ExtractionForcepsOther
APGAR Score:
Did your child have a misshaped skull/head

YesNo
Were there purple marks on their face?

YesNo
Did/do you breastfeed your child?

YesNo
Does your child prefer one breast over the other?

YesNo
If yes, which side?
Does your child have any food allergies?*

YesNo
If yes, please list:
Has your child been immunized?*

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

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

YesNo
If yes, please elaborate:
Has your child had either of these procedures?*

Tongue TieLip TieNone of the above
Has your child been on antibiotics?

YesNo
If yes, how often and what for?
Is your child currently taking any medications?*

YesNo
If yes, how often and what for?
Is your child currently taking any vitamins?*

YesNo
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 tableFall out of a cribTonsillitisConstipationFrequent crying spellsFall off of playground equipmentSleeping problemsTumble down stairsFrequent feversRepeated infections or coldsInvolvement in MVAFrequent ear infectionsFrequent diarrheaColic
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 treeStomach painsHyperactivity/AutismLeg/knee painsFall off of a bicycleScoliosisLearning difficultiesSports accidentBed wettingAsthmaInvolvement in MVAFall on playgroundAllergiesOther
Primary Health Complaint:
When did it begin?
Has it affected the child's activity?

YesNo
Please list all sports activities your child is involved in:
How would you rate your child's diet?

Well balancedAverageHigh sugar/processed foods
Does your child consume artificial sweeteners?

YesNo
Does your child consume fluorinated water?

YesNoNot sure
On average how many hours of sleep does your child get?
How is the quality of their sleep?

GoodFairPoor
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)