Return Foster Family Chiropractic
Pediatric History Form
           When complete, please print this form and bring it with you to your first appointment.
       Should you require additional space to complete the form, please refer to Additional Comments near the bottom.
Patient Information
First Name Last Name
Street Address Apartment
Town/City Province Postal Code
Home Phone Work Phone  
E-Mail
Birth Date   Age Sex
Height cm in Weight kg lbs
Names of Parents / Guardians:
How did you hear about our office?
Were you referred to this office? Yes No
     If yes, by whom?
Medical History
Purpose for contacting us?
How long has your child experienced this?
Is it getting better or worse over time?     Better Worse
Other health care professionals consulted for this problem
Other health problems?
Select any of the following that your child now experiences or has experienced in the past:
Ear Infections Scoliosis Seizures Chronic Colds Headaches
Asthma / Allergies Digestive Problems Sinus Troubles Recurring Fevers Bed Wetting
Colic Growing Pains Eczema / Skin Problems Neck Pains Temper Tantrums
Allergies Back Pains Constipation / Diarrhea Attention Problems - ADD/ADHD
Bronchitis / Upper Respiratory Infections
Other Specify Other
Are you content with your child's present level of health?    Yes No
    Please Explain
   
Previous Chiropractor
    Reason for Visits
   
Has your child been treated by a physician for any condition in the previous 12 months?    Yes No
    If yes, please explain.
   
Is your child currently taking any medication?     Yes No
    If yes, please list along with reason.
   
Has your child taken any medication for an extended period of time in the past?     Yes No
    If yes, please list along with reason.
   
Does your child take any herbal or vitamin supplementation?     Yes No
    If yes, please list.
   
Number of doses of antibiotics your child has taken:
    During the past 6 months:         During his/her lifetime:
Number of doses of other prescription medications your child has taken:
    During the past 6 months:         During his/her lifetime:
    List:
   
Has your child received vaccinations?     Yes No
Does your child exercise?     Yes No
    What type of exercise?
   
Prenatal History
Name of Midwife / Obstetrician Ultrasounds during pregnancy? Yes No
Medications during pregnancy?     Yes No
Medications during labour/delivery?     Yes No
    If yes, please list
   
Were you induced?     Yes No
Was your child at any time during your pregnancy in an intra-uterine constraining position such as:
    Breech      Transverse Lie (side lying)      Face/Brow Presentation
Was your delivery vaginal?     Yes No
Was your delivery C-Section?     Yes No
    If so, was it planned or emergency?     Planned Emergency
Were any of the following used during delivery?    Forceps     Vacuum Extraction     Other
    If other, list
   
Any Complications During Delivery?     Yes No
    If yes, explain
   
Location of birth    Hospital     Birth Centre     Home
Weight    kg lbs Length    cm in
Feeding History
Breast Fed:     Yes No
     If yes, how many months?    
Formula Fed:     Yes No
     If yes, Type?     
Introduced to solids at:       months              Cow's milk at:       months
Food Sensitivities
Developmental History
During the following times your child's spine is most vulnerable to stress and should routinely be checked by a Doctor of Chiropractic for prevention and early detection of vertabral subluxation (spinal nerve interference).
At what age was your child able to:
    Hold head up:           Sit up:           Cross Crawl:   
 
    Walk Alone:   
Has your child ever fallen from a high place? (bed, change table, sofa, down stairs, etc.)    Yes     No
    If yes, please explain
   
Is/was your child involved in any impact or contact sports?
(soccer, football, gymnastics, baseball, roller or ice hockey)    Yes No
    If yes, please explain
   
Has your child ever been involved in a car accident?    Yes No
    If yes, please explain
   
Has your child ever been seen on an emergency basis?    Yes No
    If yes, please explain
   
Other Traumas?     Yes No
    If yes, please explain
   
Prior Surgery?     Yes No
    If yes, please explain
   
Childhood Illnesses
Please indicate if your child has experienced any of the following illnesses, and if so, at what age (year).
Chicken PoxAge MumpsAge Rubella   Age
Whooping Cough   Age Rubeola   Age OtherAge
If other, please list   
Additional Comments
     
Consent for Care
Doctors of Chiropractic, Medical Doctors and Physical Therapists using manual therapy treatments for patients with neck problems are required to explain that there have been rare cases of injury to a vertebral artery as a result of treatment. Such an injury has been known to cause stroke, sometimes with neurological injury. The chance of this happening are extremely remote, approximately 1 per million treatments.

Appropriate tests will be performed on you to help identify if you may be susceptible to that kind of injury. Dr. Foster and Dr. Butt use a variety of techniques in this office; many techniques do not involve manual therapy, especially those for infants, elderly and pregnant mothers. If you have any questions about this, please do not hesitate to speak with the doctor.

I understand that the spinal adjustments offered in this office are not a replacement for any form of treatment provided by other types of practitioners. I understand that I am not being treated for any symptom or condition other than spinal subluxation. This office offers chiropractic as a form of health and wellness care, to promote the natural mechanisms for self-healing and empowerment.

I have read and understood the above statement, accept the risk, and hereby consent to chiropractic care.

Date  
Name of Child
Signature of Parent or Guardian
Please complete this form prior to arriving at our office. If you have any questions, please do not hesitate to contact our office at 905-898-8098, or wait until your appointment time. We are excited that you have chosen Dr. Laura Foster & Associates for your chiropractic care. It is our pleasure to welcome you and your family to the most natural form of health care, chiropractic.
Instructions for First Appointment
Our office utilizes the most advanced form of non-invasive diagnostic procedures available. Please refrain from intense exercise 6 hours prior to your appointment time, as well as avoiding heat/ice, caffeine and over-the-counter (non-prescription) medications. These may interfere with the quality of your diagnostic results. Please call if you have any questions.

We look forward to seeing you.