Location

Serenity Health Chiropractic

Address
60 2nd St Unit C-7,
Shalimar, FL 32579 US

Phone
(850) 613-4125

Fax

(850) 613-4148

Email
[email protected]

Read More

Call Us (850) 613-4125

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About Us
Our Services
Pregnancy & Pediatric Care
New to Our Office
Contact Us

Serenity Health Chiropractic

Phone
(850) 613-4125

Home
About Us
Our Services
Pregnancy & Pediatric Care
New to Our Office
Contact Us

Home

Children's Health History Form

Children's Health History Form

Please allow our staff to photocopy your driver’s license and insurance details. All information you supply is confidential. We comply with all federal privacy standards. Please print clearly.

Parent’s Name*

Date

About your child

Your Child’s Last Name

Your Child’s First Name

Birth Date

Age & Gender

Height

Address

City

State/Province

ZIP/Postal Code

Home Phone *

Parent’s Employer

Work Phone

Cell Phone

E-mail Address *

Payment Method

Credit Card Details

Exp. Date

Insurance Carrier

Policy Number

Policy Group Number

Policy Holder’s Name

Primary Care Provider’s Name

Policy Holder’s Social Security#

Mother’s pregnancy & labor

During the pregnancy did the mother take any medication?

Yes No

Explain

Smoke or consume alcohol?

Yes No

Explain

Experience any illness?

Yes No

Explain

Approximately how long did the labor last? in hours

Was labor chemically induced?

Yes No

Was labor doctor assisted?

Yes No

Was a C-Section performed?

Yes No

Were forceps or vacuum extraction used?

Yes No

Did the delivery doctor pull or twist the baby during delivery?

Yes No

Was the delivery premature?

Yes No

If yes at

Check any of the following if the child experiences it.

Yes No

Feeding problems

Yes No

Respiratory problems

Yes No

Displaced or broken Joints

Yes No

Other condition(s)

Your child’s current health status:

Yes No

Has your child been hospitalized?

Yes No

Had a severe fall?

Yes No

Been in a car accident?

Yes No

Has your child ever taken any antibiotics?

Yes No

If yes explain

Is your child currently taking any medication?

Yes No

If yes explain

Does your child have difficulty interacting with schoolmates or friends?

Yes No

Have you or anyone else noticed that your child is nervous, twitches, shakes, or exhibits rocking behavior?

Yes No

What changes (if any) in your child’s health or behavior would you like accomplished?

Reason for today’s visit

Is the purpose of this appointment related to?

Sports

Yes No

Auto

Yes No

Fall

Yes No

Home injury

Yes No

Chronic discomfort

Yes No

Other

Yes No

Explain

When did this condition begin?

Explain

Has this condition gotten worse?

Yes No

Stayed constant?

Yes No

Comes and goes?

Yes No

Does the condition interfere with Sleep?

Yes No

Daily routine?

Yes No

Other activities?

Yes No

Explain

Has this condition occurred before?

Yes No

Explain

Have you seen other doctor’s about this condition?

Yes No

Dr.’s Name(s)

Type of treatment

Results

Your Child’s health history

Vision problems Pink Eye Headache Ear problems Sleeping disorder Tubes in the ear Irritability Attention problems Skin problems Frequent colds Allergies Colic Breathing problems Digestive problems Asthma Hyperactivity Constipation Bed Wetting Other

Explain

Goals for my child’s care

Relief care- symptomatic relief of pain or discomfort Corrective care – correcting or relieving the cause of the problem as well as the symptoms Comprehensive care – bring whatever is malfunctioning in the body to the highest state of health possible with chiropractic care. I want the doctor to select the type of care appropriate for my child.

Vaccinations

Yes No

If “Yes” please check all the vaccines the child has received.

DPT MMR Polio Chickenpox Hepatitis

Other

Describe any and all reactions to vaccine(s)

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Location

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Serenity Health Chiropractic

Address

60 2nd St Unit C-7
Shalimar, FL 32579

Contact Information (850) 613-4125

(850) 613-4148

60 2nd St Unit C-7
Shalimar, FL 32579

(850) 613-4125

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