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PAEDIATRIC INTAKE & HISTORY

Client Consent 
At CBD Health Plus (Chiropractic) we aim to provide the highest quality care. Part of this care may involve cervical (neck) manipulation. We feel it is important that as with any health care procedure there is some risk associated with cervical manipulation. This risk is currently estimated at 1 in 1,000,000 for stroke or stroke like symptoms. This is a rare and unpredictable event. Other risks that can be associated with spinal adjustments include disc injuries, rib fractures, sprains/strains or pre-existing conditions may be aggravated. We take every precaution to ensure that risk is minimized through thorough testing, examination and the use of gentle and specific techniques. If you have any concerns, please let your chiropractor know. I acknowledge that I have been informed of the risks involved and understand that if at any time I have concerns that can be discussed with my chiropractor. I appreciate that I will receive the best care possible at CBD Health Plus (Chiropractic) but that results cannot be guaranteed. I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor deems necessary. I understand that any fee for service rendered is due at the time or service and cannot be deferred to a later date.

Dated: November 26, 2020 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Home Phone:

Mother's Name:

Mother's Occupation

Mother's Phone

Mother's Email

Father's Name

Father's Occupation

Father's Phone

Father's Email

Who may we thank for referring you?

HOW CAN WE HELP YOUR CHILD?

SERVICE*

If other is selected:

If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?*
No
Yes

Please describe:

PREGNANCY HISTORY 

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Strep B
Nauseau/Vomitting
Pre-Term
Fatigue
Swelling
Other

If Other, please provide additional details.

BIRTH HISTORY 

Type of birth (check all that apply):
Hospital
Birth Center
Home
Normal / Vaginal
Breech
Cesarean
Scheduled/Induced
Epidural

Problems during labor / delivery?
Problems during labor / delivery?
Antibiotics
Congenital Anomalies
Failure to Thrive
Jaundice
Meconium
Respiratory Distress
Extended Hospitalization
Other

Other

GROWTH & DEVELOPMENT 

Infant feeding:
Breast
Bottle
Formula

Number of hours of sleep each night:

Quality of sleep:

At what age did the child:

Respond to sound:

Crawl:

Hold head up:

Stand:

Sit unsupported:

Walk unsupported:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child had (check all that apply)?:
Chicken Pox
Measles
Rubeola
Mumps
Rubella
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anemia
Arm Problems
Asthma
Back Aches
Bed Wetting
Behavioral Problems
Broken Bones
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Digestive Issues (constipation/diarrhea)
Dizziness
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Jeuvenile Rheumatroid Arthritis
Joint Problems
Leg Problems
Neck Problems
Neuritis
Orthopedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?*

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY 


ALLERGIES (list)

MEDICATIONS (list)

SURGERIES (list)

FAMILY HISTORY (list)

SIBLINGS 


How many children do you have?

Children's' Ages:

Childrens' health concerns:

Number of pregnancies:
Are you currently pregnant?

Yes, I'm due:

Health concerns regarding this pregnancy?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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