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info@pojerofamilychiropractic.com

Home
Services
- Adult Chiropractic Care
- Kids Chiropractic Care
About Us
Subluxation
- Subluxation
- Spinal Degeneration
Forms
Contact Us

Child Health History Form

Download Child Health History Form

Please either download the form, complete it and bring it to your appointment or fill out the form below and click submit.

We are happy you have chosen to have your child's spine checked! Many types of stresses (physical, mental, and chemical) can interfere with your child's growing spine and nervous system. Spinal health is an exciting new concept for many people, so PLEASE ask questions.

Child's Name

Date Of Birth

Age

Address

City/State/Zip

Parent's Email

Home Phone #

Parents Cell Phone #

Mother's Name

Father's Name

Names & Ages of Siblings

Reasons for Consulting Our Office

Referred By

Previous Chiropractic Care?

Previous Chiropractic Care?

Yes
No

With Whom?

How Long Was Care Received?

Reason for Stopping Care?

Background Information

CHECK OFF APPROPRIATELY

Birth Place:

Home
Birth Center
Hospital

Type:

Vaginal
C-Section

Procedures:

Forceps
Vacuum Extraction

Was Delivery Long?

Yes
No

Was Delivery Difficult?

Yes
No

Labor Induced?

Yes
No

Epidural?

Yes
No

Pain Medication?

Yes
No

Was Baby Breech/in Utero-Constraint?

Yes
No

Was Baby Breast Fed?

Yes
No

How Long?

Which sports does/did your child participate in:

Soccer
Football
Gymnastics
Cheerleading
Karate
Basketball
Dance
Lacrosse
Other

If Other Please Describe:

According to the National Safety Council, approximately 54% of infants fall head first from a high place (bed, changing table, etc.) during their first year of life. Has this happened to your child?

Yes
No

Please Explain

Comments:

List any other fall or accidents:

Check any of the following your child has suffered from:

Ear Infections
Scoliosis
Seizures
Chronic Colds
Asthma/Allergies
Digestive Problems
Headaches
A.D.D.
A.D.H.D.
Recurring Fevers
Growing/Back Pains
Colic
Bed Wetting
Constipation
Head Banging

Other ailments your child has suffered from:

Medications

How many rounds of antibiotics has your child taken in last 6 months?

Lifetime?

Present Prescription Drugs

Past Prescription Drugs

Over the Counter Drugs (Tylenol, cough syrups, laxatives, etc.)

FINANCIAL INFORMATION

Who is responsible for this account?

Relationship?

Date Of Birth

Employer

What method of payment will you be using?

Insurance
Cash
Check
Other

Insurance Company

Policy/ID#

Address

Phone #

AUTHORIZATION FOR CARE OF A MINOR

I hereby authorize:

and whomever they may designate to administer care to my son/daughter:

Signature

Relationship to minor:

Date:

Witnessed:

(In office use only)

Email

Pojero Family Chiropractic

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Contact Us:

Pojero Family Chiropractic
153 Main Street, Sayville, NY 11782
631-244-0300
info@PojeroFamilyChiropractic.com
www.PojeroFamilyChiropractic.com

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Send us an email and we'll get back to you, as soon as possible.

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Home
About Us
Adult Chiropractic Care
Kids Chiropractic Care
Subluxation
Spinal Degeneration
Testimonials

Contact Us:

Pojero Family Chiropractic
153 Main Street, #2, Sayville, NY 11782
(631) 244-0300
info@pojerofamilychiropractic.com
www.pojerofamilychiropractic.com

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Location:

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Home
About Us
Adult Chiropractic Care
Kids Chiropractic Care
Subluxation
Spinal Degeneration
Testimonials