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Pediatric Intake
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Please enter your child's information.
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First Name
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Prior Chiropractic Care
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Last Name
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Name of previous practitioner(s)
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Date of Birth
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Phone number for previous practitioner(s)
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Gender
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Length of treatment to present
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Name of Mother
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Date of last visit
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Name of Father
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Results Achieved
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Street Address
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Current Concern
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Apt./Unit #
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Please describe your child's current health concerns and how it began-- in order of priority.
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City
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What aggravates this condition?
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State
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What improves this condition?
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Zip Code
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Has your child had any serious conditions, illnesses, injuries, and/or hospitalizations in the past?
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Phone Number
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If yes, please provide approximate dates.
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Email
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Prenatal Questions
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Preferred method of contact
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Location of Birth
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Medical History
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Complications during pregnancy? Please list.
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Height
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Number of ultrasounds during pregnancy:
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Weight
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Medications during pregnancy/delivery:
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Does your child have any allergies (medicine, cosmetics, environmental, foods)?
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Cigarette or alcohol use during pregnancy?
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Please list any previous surgical procedures and any details/hardware (i.e. prosthesis, wires, internal pins/fixators).
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Birth intervention? (forceps, vacuum, caesarian, etc.) Why?
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Please list all current medications (prescription, over-the-counter, vitamins, herbs, homeopathics).
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Complications during delivery? Please list.
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Please specify dates and dosage of medication usages.
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Genetic disorders or disabilities? Please list.
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Has your child ever taken antibiotics?
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Birth weight
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Has your child ever fallen head first?
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Birth height
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Has your child ever been injured playing a contact sport?
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Breast fed? If yes, for how long?
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If yes, what sport and what injury?
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Formula fed? If yes, for how long?
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Type of formula:
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Introduced to solids at ___ months
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Introduced to cow's milk at ___ months.
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Food/juice allergies or intolerances? If yes, please list.
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