Initial Child & Adolescent Questionnaire
Full Name
Age
Date of birth
Address
City
Postal code
Mother's name
Father's name
Email
Cell Phone
Grade
Sports and hobbies
How did you hear about us? Who may we thank for referring you?
Current pediatrician
City of Pediatrician
Have you or your child ever received chiropractic care?
Yes
No
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Name of D.C.
Mainly for Moms:
Tell us about your pregnancy
Did you carry to full term
Describe any complications and when they occurred
Tell us about the delivery and birth of this child:
Did you use a midwife?
Hospital?
Obstetrician?
Did you have a C-section?
Were forceps used?
Vacuum extraction?
Were you induced?
Did you have an Epidural?
Was it a difficult birth?
Tell us more
Did you breastfeed?
What formula after?
Did you consume alcohol during your pregnancy?
Did you smoke?
Did you take any medication during your pregnancy?
As a baby/toddler, (birth to 4 years), did any of the following occur?
Fall from a change table
Frequent crying spells
Tumble down stairs
Frequent fevers
Fall out of crib
Frequent bouts of diarrhea
Involved in car accident
Constipation
Fall off playground equipment
Sleeping problems
Play in “Jolly Jumper”
Frequent colds
Frequent ear infections
Colic
“Growing Pains”
Did not gain weight
Reaction to vaccination
Other
Please explain the above:
As a young child, (5-12 years), did any of the following occur?
Fall from a tree
Bed wetting
Fall of a bicycle
Hyperactivity/Autism
Fall of playground equipment
Learning difficulties
Sports accident
Asthma
Car accident
Allergies
Stomach pains
“Growing Pains"
Scoliosis
Other
Please explain any of the above:
As a child or adolescent, has your child experienced any of the following:
Headaches
Numbness in arms/hands
Foot/ankle/knee pains
Dizziness
Arm/wrist pains
Tingling in arms/legs
Ringing in ears
Sleeping problems
Neck/back pains
Asthma
Allergies
Shoulder pains
Hyperactivity
Stomach problems
“Growing Pains”
Fatigue
Weight gain/loss
Other
Please explain any of the above:
Which of the above problems you have checked off is the worst?
How long has it persisted?
When it is at its worst, how does it make your child feel?
What have you done about it that has NOT worked?
What makes it worse?
What effect does this problem have of your child’s body functions?
On his/her participation in daily activities?
Describe any hospital stays:
Approximately how many times have antibiotics been prescribed, and for what conditions?
To summarize, what is your purpose for this appointment?
Is there anything else you feel we should know?
The information I have provided on this form, is true and accurate to the best of my knowledge. I give Dr. Michael P. Griffin permission to render care today. This initial visit includes a health history/consultation, chiropractic exam/evaluation. I also give my consent to have the doctor order any x-rays that he deems appropriate, and any initial care that is determined to be clinically necessary and mutually agreed upon.
Signature of Parent (for minor):
Clear
Today’s Date