Form

New Child Information Form (Under 13)
Patient Contact Information
Patient Name*
First Name Last Name
Guardian filling out form
First Name Last Name
E-mail*
Home Phone*
- Area Code Phone Number
Work Phone
- Area Code Phone Number
Cell Phone
- Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Insurance Information

For auto or work comp. use policy one and add date of accident
Insurance Company 1
Blue Cross, Blue Sheild, Aetma, Cigna, State Farm ect. (for multipal insurance companies use commas)
Policy Number 1
Group Number 1
Date of Accident
Month Day Year
Insurance Company 2
Blue Cross, Blue Sheild, Aetma, Cigna, State Farm ect. (for multipal insurance companies use commas)
Policy Number 2
Group Number 2
Personal Information
Birth Date*
Month Day Year
Social Security Number
Drivers Licence Number & State
Sex*
Marital Status*
Spouse's Name
First Name Last Name
Spouse's Phone
- Area Code Phone Number
Doctor's Name
First Name Last Name
Doctor's Phone
- Area Code Phone Number
Emergency Contact
First Name Last Name
Emergency Contact
- Area Code Phone Number
Child Name 1
First Name Last Name
Child Name 2
First Name Last Name
Child Name 3
First Name Last Name
Child Name 4
First Name Last Name
Additional Children
Work History
Please include emplyers name, addres, phone, possition held, and number of years. Most recent first. Enter None if not aplicable.
How did you hear about us?
Child Health History
Chief Health Concerns*
List other care for this complaint*
Date of onset*
Month Day Year
Onset was*

Sudden Gradual
Duration of current episode*
min./ Hr./ days/ months/ years
Associated Events*
What makes this condition worse*
What makes this condition better*
Other health concers*
Where was your child born*
Who assisted with the birth*
Doctor, Midwife, Doula
Was delivery assisted*

Forceps Vacuum Extraction C-Section Labor Induced None
Medications delivered to mother around birth*
Complications at birth*
APGAR (if known)*
Birth weight*
Birth length*
Delivery nornal*

Yes No
Was the infant responsive within 12hrs. of delivery*

Yes No
At what age did your child respond to sound*
At what age did your child follow objects*
at what age did your child hold head up*
At what age did your child vocalize*
At what age did your child sit unaided*
At what age did your child teethe*
At what age did your child crawl*
At what age did your child walk*
Do the child's sleeping patterns seem normal*

Yes No
Was the child breast fed*

Yes No
Type of formula used*
Formula introduced at what age*
Cow's milk introduced at what age*
Age introduced and type of baby food*
Age introduced and type of solid food*
Food and juice intolerance explain*
During pregnancy did the mother smoke*

Yes No
During pregnancy did the mother drink*

Yes No
During pregnancy did the mother Take supplements*

Yes No
List supplements
During pregnancy did the mother take medications*

Yes No
List medications
Did the mother have any illnesses during pregnancy*
During the pregnancy was the child exposed to ultrasound*

Yes No
What was the medical reason
How many
Any invasive procedures*

Yes No
Which procedures
amniocentesis, CVS, etc.
Any pets in the home*

Yes No
Type and number of pets
Has the child been vaccinated*

Yes No
List vaccinations and any reactions
Has the child taken antibiotics*

Yes No
Antibiotics were for what and total number of courses?
Any behavioral problems*

Yes No
Explain behavioral problems
Any bonding problems*

Yes No
Explain bonding problems
Any night terrors*

Yes No
Any sleepwalking*

Yes No
Any sleeping difficulty*

Yes No
Does your child seem normal for their age*

Yes No
Hours of TV per week
Any traumas during pregnancy*

Yes No
Explain traumas
Any evidence of birth trauma*

No bruises odd shaped head stuck in birth canal fast/slow delivery respiratory distress cord around the neck
Any falls (explain)
Any traumas (explain)
Any hospitalizations (explain)
Any surgeries or organs removed (explain)
Sports
(list: age started and number of hrs per week)
Email of parent or guardian acts as signature
E-mail
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New Child Information Form (Under 13)

Patient Contact Information

Insurance Information

Personal Information

Child Health History

Email of parent or guardian acts as signature