Pediatric Patient Form Chiropractic Care Order Number Dear Parent Please complete this questionnaire. Your answers will determine if Chiropractic can help your child. Please answer ALL questions, even if they seem unrelated to your child. There are conditions Chiropractic can help of which you may be unaware of. If we do not sincerely believe the condition will respond satisfactorily, we will not accept the case. Personal History Name: * Date: Alberta Health Care No. Phone #: Address: Postal Code: Age: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Weight: Height: Parents: Birthdate: Birthplace: School: Family Doctor: Referred to this office by: Current Health Condition Present Complaint: Previous treatment for this condition: When did this condition begin? What do you believe caused this condition? Are there others in you family with this same condition? Presently taking medication? (Please list) Past Health History Surgery / Operations: Appendix Tonsils Hernia Tubes in ears Other: For newborns; birth process: Normal Easy Hard Abnormal Major injuries, falls, fractures (etc...) Previous Chiropractic care Yes No Last Chiropractic Visit Name of Dr. Treatment for any health conditions in the last year: Yes No If health conditions, please explain: Any reaction to vaccinations / medications: Yes No If reactions, please explain: Please check any of the following conditions that are a problem, and click 'past' if they were a problem in the past. Muscle & Joint: sore muscles sore joints growing pains muscle cramps back problems neck problems painful tailbone pain between shoulders spinal curvature arthritis difficulty chewing/clicking jaw general stiffness walking problems feet turn in/out coordination problems headaches Organic: bedwetting constipation/diarrhea anemia thyroid vomiting skin eruptions/eczema General: fatigue allergies difficulty sleeping dizziness fainting earaches nosebleeds sore throat asthma chronic cough enlarged glands loss of weight poor/excessive appetite junk food nervousness depression/confusion visual problems dental problems hearing problems hyperactivity behavioural problems frequent colds/flu epilepsy rheumatic fever stomach aches I am authorized to and do give authorization for this child to be treated.