Fuller Chiropractic - Dr. Scott Fuller, DC and Dr. Kandyce Dewar, DC

 

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Child History Form

 CHILDREN’S HISTORY FORM

 

 

Name:                                                                                                                        Date: __________________

Street Address:_______________________________City/State:_________________________Zip:_______

Home Phone:_____/_____/______  Parent’s Work:_____/_____/______ ext:___  Cell:_____/_____/_____

Date of Birth:________/________/________ Age:____________     Height:             Weight:                        

Father’s Name: __________________________      Mother’s Name: _______________________________
Guardian: ___________________________ Who referred you here?_______________________________

 

COMPLAINTS/HEALTH PROBLEMS

o My child is here for a general health evaluation.   o My child is suffering from a particular health problem.

Please describe your child’s complaints, including when and how they started:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What treatments and tests has your child received for his/her problems so far? __________________________________________________________________________________________

__________________________________________________________________________________________

Has your child ever seen a chiropractor? __ Y __ N Who? ________________________________________

Who is your child’s pediatrician?  Name: ___________________________     Location: _________________

When is the last time your child visited his/her pediatrician?  Date:______________ 

Reason: __________________________________________________________________________________________________

Please list any major childhood traumas with dates and hospitalizations. 

____________________________________________________________________________________________________________________________________________________________________________________

Is your child taking any over the counter or prescription medication? ________________________________

______________________________________________________________________________________

Is your child taking any vitamins/supplements? _________________________________________________

What illnesses has your child had (measles, chicken pox, etc.)?

_________________________________________________________________________________________

 

Check any of the following conditions your child has had or does have:

 

__ Allergies

 

__ Ear Infections

 

__ Autism

 

__ Neck Pain

__ Sinus Problems

 

__ Headaches

 

__ Tourette’s Syndrome

 

__ Mid Back Pain

__ Asthma

 

__ Migraines

 

__ Dyslexia

 

__ Low Back Pain

__ Depression

 

__ Menstrual Problems

 

__ Dyspraxia

 

__ Shoulder Pain

__ Type 1/2 Diabetes

 

__ Dizzy/Balance Problems

 

__ LD (Learning

 

__ Elbow Pain

__ Digestive Problems

 

__ Colic

 

Disability)

 

__ Hand Pain

__ Weight Problems

 

__ ADD-AD/HD

 

__ ODD (Oppositional Defiant)

 

__ Hip Pain  L  R

__ Drug Abuse/Addiction

 

__ OCD (Obsessive Compulsive)

 

___ Other _______

 

__ Leg Pain  L  R

__ Eczema

 

__ PDD (Pervasive Developmental)

 

_______________

 

__ Knee Pain  L R

__ Other Skin Problems

 

__ Asperger’s Syndrome

 

_______________

 

__ Foot Pain  L  R

 


 

 

o Yes  oNo   Any personality/emotional changes?  If so, what are they? ____________________________

o Yes  oNo   Any changes to your child’s sense of smell? 

o Yes  oNo   Does your child see spots or any disturbances to their vision?

oYes   oNo   Does your child’s eyes and/or mouth get dry?

o Yes  oNo   Does your child break a sweat easy?

o Yes  oNo   Does your child sweat more on one side of the body than the other?

o Yes  oNo   Does your child choke on foods or liquids?

o Yes  oNo   Does your child consume caffeine (coffee, soda, tea)?  How much? _____________________

o Yes  oNo   Does your child move his/her bowels daily?

o Yes  oNo    Any changes in your child’s bowel function? _______________________________________

o Yes  oNo   Can your child easily initiate a stream of urine, and is he/she able to empty his/her bladder fully?

o Yes  oNo   Any changes to your child’s urination? ____________________________________________

o Yes  oNo   Have you noticed any short or long-term memory changes?                                   

o Yes  oNo   Does your child fatigue easily?

o Yes  oNo   Does your child have any muscle twitches?

o Yes  oNo   Is your child involved in any sports or hobbies?  If so, what? ___________________________

______________________________________________________________________________________

What is your child’s typical diet? ____________________________________________________________

______________________________________________________________________________________

Siblings, ages, and health: _________________________________________________________________

 

I, the undersigned, being the parent/guardian of ____________________, certify that the above information is correct.  I authorize Fuller Chiropractic to perform an examination, take x-rays if necessary, and administer chiropractic treatment for this child.  I authorize Fuller Chiropractic to contact and release information to other health care providers the child has to coordinate care, and to release health information for insurance reimbursement purposes.

 

_____________________________________             _______/_______/_______

Parent/Guardian Signature                                                                                   Date


Fuller Chiropractic 576 Main St., Woburn, MA 01801
781-933-3332

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