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:
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What treatments and tests has your child received for his/her problems so far? __________________________________________________________________________________________
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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.
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Is your child taking any over the counter or prescription medication? ________________________________
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Is your child taking any vitamins/supplements? _________________________________________________
What illnesses has your child had (measles, chicken pox, etc.)?
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Check any of the following conditions your child has had or does have:
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__ Allergies
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__ Ear Infections
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__ Autism
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__ Neck Pain
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__ Sinus Problems
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__ Headaches
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__ Tourette’s Syndrome
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__ Mid Back Pain
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__ Asthma
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__ Migraines
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__ Dyslexia
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__ Low Back Pain
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__ Depression
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__ Menstrual Problems
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__ Dyspraxia
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__ Shoulder Pain
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__ Type 1/2 Diabetes
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__ Dizzy/Balance Problems
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__ LD (Learning
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__ Elbow Pain
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__ Digestive Problems
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__ Colic
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Disability)
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__ Hand Pain
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__ Weight Problems
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__ ADD-AD/HD
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__ ODD (Oppositional Defiant)
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__ Hip Pain L R
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__ Drug Abuse/Addiction
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__ OCD (Obsessive Compulsive)
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___ Other _______
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__ Leg Pain L R
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__ Eczema
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__ PDD (Pervasive Developmental)
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__ Knee Pain L R
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__ Other Skin Problems
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__ Asperger’s Syndrome
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__ Foot Pain L R
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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? ___________________________
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What is your child’s typical diet? ____________________________________________________________
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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.
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Parent/Guardian Signature Date
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