Patient's Name *

First Name

Last Name

Patient's DOB *

MM

DD

YYYY

Parent Phone *

(###)

###

####

Name of person completing the form. *

First Name

Last Name

Which of the following did you experience during pregnancy? *

Morning sickness

Indigestion/heartburn

High/low blood pressure

Gestational diabetes

Swelling

Thyroid problems

Back pain

None of the above

Did you fall or have a motor vehicle accident while pregnant? *

Yes

No

Did you use any of the following while pregnant? *

Cigarettes

Alcohol

Prescription/over the counter medication

None of the above

Which of the following applies to your labor and delivery? *

Hospital birth

Home birth

Planned C-section

Emergency C-section

Induced birth (Pitocin)

Forceps

Vacuum extraction

Epidural

What was your child's head position? *

Head presentation

Breech presentation

Face presentation

Unknown

Was the baby...? *

Full term

Premature

Was intensive care required? *

Yes

No

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

Back/neck pain

Pain in legs or arms

Torticollis (Severe head tilt)

Headaches

Ear infections

Tubes in ears

Has frequent upper respiratory tract infections

Had colic as an infant

Asthma

Allergies

Constipation

Bed-wetting

Skin problems (Eczema, rashes..)

Childhood diseases

None of the above

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

Fall from a bicycle, skate board..

Fall down stairs

Fall from a significant height

Motor vehicle accident

Injuries (Fracture, burn, cut..)

Trips and falls easily

None of the above

Is your child a good eater? *

Yes

No

He/she is too young for solids

Does your child have any food allergies? *

Yes

No

I don't know

Does your child take any supplements? *

Yes

No

Does your child sleep well? *

Yes

No

Does your child have frequent temper tantrums? *

Yes

No

Does your child cry a lot? *

Yes

No

Do you think your child has good balance? Do you think your child has good balance? Do you have any concern about your child's health? *

Yes

No

I don't know

Does your child go to daycare? *

Yes

No

Is there a smoker in your household? *

Yes

No

Did you choose to have your child vaccinated? *

Yes

No

Did your child ever have a reaction to an immunization? *

Yes

No