Chiro Child Intake Form Page 2
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4Prenatal History:
Did Mom carry to full term?
Y
N If not, how many weeks? ____________
Was Mom on any medications?
Y
N
If so, what? __________________________________________
Was baby ever in the breech position?
Y
N Was Mom induced?
Y
N
How many ultrasounds were performed? ________ How often? _____________________________________
Birth and Delivery:
Where was baby born?
Home
Birthing Center
Hospital
Was the delivery:
Vaginal
C-Section
Did they use:
Forceps
Vacuum
How long was the labor? _____________ Did Mom have:
Pitocin
Epidural
Antibiotics
Were there any complications? ________________________________________________________________________
Infancy:
Did Mom breastfeed?
Y
N How long? __________ Was one breast preferred?
R
L
Was your child vaccinated?
Y
N Did your child have any negative reactions?
Y
N
Has your child been on antibiotics?
Y
N How often/why? ____________________________________
Sleeping Habits
Position:
Face down
Face up
On Right/Left side
How many hours? _____________ Straight through or how many wakes? ______________
What causes your child to wake? ________________________________________________________________________
Healthy Eating
How many glasses (8oz) of water does your child drink daily? _____________
Please list favorite foods: _________________________________________________________________________________
Any sensitivities to certain foods?
Dairy
Gluten
Meats
Other: __________________________
Does your child eat artificial sweeteners?
Y
N Drink sugary beverages?
Y
N
Is there anything else which may help us to understand you and your child’s needs which has not
been discussed on this survey? ______________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Please read the statements below and check the boxes next to those with which you agree:
I certify that information provided to this office is up to date and correct to the best of my knowledge.
I authorize the release of any medical information necessary to process claims submitted to my insurance.
I authorize payment of any medical benefits directly to this clinic for any services rendered to me.
I am the authorized parent or guardian of this child and authorize this office to treat my child.
Printed Name of Child: ____________________________________________________________________________________________
Signature of Parent: ________________________________________________________________________ Date: _______________
Thank you for taking the time to provide us with this vital information.
We are here to serve you!
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