Has your child been on antibiotics? Yes/No If yes, how often and what purpose? Is your child currently taking any medication? Yes/No If yes, how often and what purpose? Is your child currently taking any vitamins? Yes/No Baby/Toddler (0-4) Have any of the following occurred? Jaundice Anemia
Colic Frequent diarrhea Constipation Sleeping problems Frequent fevers Frequent crying spells Repeated colds
Reflux Fall from a changing table Fall out of crib Fall off playground Tumble down stairs Play in a Johnny Jumper Car accident
Cyanosis Seizures Infections Tonsillitis Frequent ear infections
Other Child (5-12) Have any of the following occurred?
Fall from a tree Fall off a bicycle Fall on playground Sports accident Car accident
Stomach pains Hyperactivity/Autism Leg/Knee pains Scoliosis Learning difficulties
Bed-wetting Asthma Allergies Growing Pains Headaches/Migraines
Other Which of the above bothers your child the most? When did it begin? Does it affect activity? ☐ Not at all ☐ Somewhat
Is it getting worse? Yes/No
☐ Always Does your child participate in any athletic extra curricular activities? Yes/No If yes, which ones? Rate your child’s diet: ☐ Well-balanced ☐ Average ☐ High sugar/processed foods Does your child consume artificial sweeteners? Yes/No Number of hours your child sleeps? hours/day Sleep quality? ☐ Good ☐ Fair ☐ Poor Is there anything else the Doctor should know?
Authorization to treat a Minor
I,
the undersigning parent/guardian having legal
custody/guardianship of _, a minor, do herby authorize, request, and direct the staff and doctors of Collins Chiropractic to perform in judgment any examination and chiropractic diagnosis or treatment which is deemed necessary. Patient’s name: Parent/Guardian’s signature: Date:
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