Pediatric Form


PEDIATRIC HISTORY FORM

PATIENT DEMOGRAPHICS

CHILD'S CURRENT PROBLEM:

Purpose of this visit*
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Ever had this problem before*
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How long ago?*
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How is this problem now?*
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Has your child ever suffered from:*
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I understand that I am directly and fully responsible to this office for all fees associated with chiropractic care my child receives.

The risks associated with exposure to x-rays and spinal adjustments have been explained to me to my complete satisfaction, and I have

conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request and authorize imaging studies and

chiropractic adjustments for the benefit of my minor child for whom I have the legal right to select and authorize health care services on

behalf of. I hereby request and authorize this office to administer healthcare as deemed necessary to my dependent minor child. This

authorization also extends to include diagnostic imaging, laboratory and other testing at the doctor's discretion.

Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify this office.*
Please select at least one option

Activities of Daily Living/Symptoms/Medications 

Daily Activities: Effects of Current Conditions on Performance:

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

Bending*
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Doing computer Work*
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Concentrating*
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Gardening*
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Playing Sports*
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Recreation Activities*
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Shoveling*
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Sleeping*
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Watching TV*
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Carrying*
Please select at least one option
Dancing*
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Dressing*
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Lifting*
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Pushing*
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Rolling Over*
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Sitting*
Please select at least one option
Standing*
Please select at least one option
Working*
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Climbing*
Please select at least one option
Doing Chores*
Please select at least one option
Driving*
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Performing Sexual Activity*
Please select at least one option
Reading*
Please select at least one option
Running*
Please select at least one option
Walking*
Please select at least one option
Sitting to Standing*
Please select at least one option

For Office Use Only

I have reviewed the above ADL & ROS form with the above named patient:

Thank you for taking the time to fill out this form.

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Office Hours

Monday:

8:45 am-12:00 pm

2:30 pm-6:30 pm

Tuesday:

Appointments Only

Wednesday:

2:00 pm-5:00 pm

Thursday:

8:45 am-12:00 pm

2:30 pm-6:30 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

Contact Us Today!

We look forward to hearing from you.