Pediatric Patient Form

Chiropractic Care

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


Current Health Condition


Past Health History

Please check any of the following conditions that are a problem, and click 'past' if they were a problem in the past.

I am authorized to and do give authorization for this child to be treated.