PEDIATRIC HISTORY OF PRESENT CONCERNS Name * First Name Last Name Date of Birth MM DD YYYY Birth Weight Current Weight Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Parent/Guardian First Name Last Name What brings you into our office today? When did it start? MM DD YYYY Have you ever had this problem before? Yes No If your child is experiencing pain/discomfort please identify where and for how long. Any bowel or bladder problems since this problem began? Yes No Have you seen any other doctors for this problem? Yes No If Yes, Who? What were the results of your tretment? Please list any medication taken for this problem. Many of the following conditions respond to Chiropractic and Acupuncture treatment. Asthma ADHD or ADD Allergies/Sinus Axiety Backaches Bed Wetting Chest Pain Chronic Earaches Constipation Digestive Problems Fever/Chills Frequent Colds Headaches Join/Muscle Pain Knee/Foot/Ankle Pain Restless Leg Syndrome Neck pain Sleep Issues Reflux/Spitting up Colic Scoliosis Torticollis Other If you chose other please elaborate. Is there anything else about your child's condition you haven't stated that you think we should know? (Medications, Vitamins, Trauma Hx, Past Surgeries, Birth Interventions) Thank you!
