Patient's Name *

First Name

Last Name

Parent Phone *

(###)

###

####

Patient's DOB *

MM

DD

YYYY

Name of person completing the form. *

First Name

Last Name

Please check if the child has had any of the following: *

Back/neck pain

Pain in legs or arms

Torticollis (Severe head tilt)

Headaches

Ear infections

Tubes in the ears

Has frequent upper respiratory tract infections

Sinusitis

Asthma

Seizures

Allergies

Constipation

Bed-wetting

Skin problems (Eczema, rashes...)

Childhood diseases

None of the above

Please check if the child has/had any of the following trauma: *

Fall from a bicycle, skate board...

Fall down stairs

Fall from a significant height

Motor vehicle accident

Injuries (Bone fracture, burn, cut...)

Head injury

Sprained joint

None of the above

Please check if anyone in your family has or ever had any of the following conditions: *

Allergies

Arthritis

Diabetes

Heart disease

Weight problems

Scoliosis

None of the above

Do you wear contacts or glasses? *

Yes

No

Do you have blurred vision? *

Yes

No

Do you ever get headaches when you read? *

Yes

No

Do you find it hard to concentrate? *

Yes

No

Do you feel stressed out? *

Yes

No

Has your child been immunized? *

Yes

No

Have you noticed a reaction to any of the shots? *

Yes

No

Has your child been diagnosed with Attention Deficit Disorder or Hyperactivity? *

Yes

No

Is there a smoker in the household? *

Yes

No