Prairielands Chiropractic Clinic - Chiropractor In Council Bluffs, IA USA

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Home > New Patient Center > Online Forms > Pediatric Online Form (Infant-10)

General Information

First Name *

Last Name *

SSN

Name of parents/gaurdians

Address *

City *

State *

Zip *

Home Phone *

Cell Phone

Email Address *

Birthdate (mm-dd-yyyy) *

Sex *

Male Female

Weight

Height

Number of siblings

Who refered you to us? *

Reason for seeking Chiropractic care

Have you seen other doctors for this condition?

YesNo

If yes, in what speciality?

Please explain any prior treatment and outcome

Symptoms

Please check any current or past problems your child has *

DizzinessADHDBackachesHeart ConditionChronic EarachesDiabetesTuberculosisHypertensionFever/ChillsFrequent ColdsArthritisHeadachesAsthmaAllergiesRunny NoseItchy EyesRashesUnusual MolesNeuritisDigestive ProblemsSinus TroubleCough/WheezeChest PainConstipationAnemiaRheumatic FeverDiarrheaPoor AppetiteHyperactivityBehavioral ProblemsPoor MemoryInsomniaNightmaresBed WettingPainful UrinationConvulsions/ParalysisMuscle PainFaintingBroken BonesSprains/StrainsHerniasNeck PainArm/Elbow PainLeg/Hip PainKnee/Foot PainGrowing PainsJoint PainsScoliosisBlood DisordersStomach AchesNoneOther

Health History

Name of Pediatrician *

Date of last visit

Reason for visit

Medications and conditions being treated *

Has your child ever taken antibiotics? *

YesNo

If yes, for what condition?

Has your child ever been injured participating in contact sports (soccer, football, martial arts, etc.)? *

YesNo

If yes, describe (sprain, broken bone, head trauma)

Has your child ever been involved in a car accident? *

YesNo

If yes, please explain

Has your child ever fallen head first from (changing table, bed, stairs, etc.)? *

YesNo

If yes, please explain

Have there been any other traumas not described above? *

YesNo

If yes, please explain

Any prior surgeries? *

YesNo

If yes, please explain

Manarche?

YesNo

If yes, at what age

Prenatal History

Location of birth

HomeBirthing CenterHospitalStepchildAdoptedOther

Complications during pregnancy?

YesNo

If yes, please explain

Ultrasounds during pregnancy?

YesNo

If yes, how many?

Medications during pregnancy/delivery?

YesNo

If yes, please list them.

Cigarette or alcohol use during pregnancy?

YesNo

Birth interventions?

ForcepsVacuumCaesarianOther

Why?

Complications during delivery?

YesNo

If yes, please explain

Genetic disorders or disabilities?

YesNo

If yes, please explain

Birth weight

Birth length

APGAR Score at 1 minute

APGAR Score at 5 minutes

Feeding History

Breast fed?

YesNo

If yes, for how long?

Formula fed?

YesNo

If yes, for how long?

What type of formula?

At what age was solid food introduced?

At what age was cow's milk introduced?

Food or juice allergies or intollerances?

YesNo

If yes, please list

Developmental History

How many hours a night does he/she sleep?

How many naps does he/she take during the day? For how long?

Are there any problems that your child has with sleeping?

At what age was your child able to:

Crawl?

Sit alone?

Stand alone?

Walk alone?

Say words?

Childhood Diseases

Has your child had:

Chicken PoxMumpsRubellaWhooping CoughMeaslesMeningitisTuberculosisOther

If any of the above apply, at what age?

Vaccination History

Has your child had all the necessary/required vaccinations?

YesNo

Have there been any adverse reactions to any vaccine?

YesNo

If yes, please explain.

Insurance Information

Insurance Company Name

Policy Number

Insurance Company Phone Number

Insureds Name

Relationship to Patient

Insureds DOB (mm-dd-yyyy)

Insureds SSN

Insureds Employer

Insureds Employer Address

Online Signiture

The above information is correct and accurate to the best of my knowledge.

Parent/Gaurdian Name

Date

Enter the verification code in the box below.

Verification Code: *

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Office Hours

Mon	8 - 12	12 - 7
Tue	8 - 12	12 - 7
Wed	8 - 12	12 - 7
Thu	8 - 12	12 - 7
Fri	8 - 12	12 - 7
Sat	8 - 2	Closed
Sun	Closed	Closed

Call Us:
(712) 256-2561

General Information

Symptoms

Health History

Prenatal History

Feeding History

Developmental History

Childhood Diseases

Vaccination History

Insurance Information

Online Signiture

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Member Login

Office Hours

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