Pediatric Intake

Welcome to our office!

Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 

About this Patient

Marital Status
Is this appointment for someone under 17 years old?*
Please select one option
Is this a result of a recent auto accident?

About the Spouse

Employer Information

Reason for this Visit

Is the purpose of this appointment related to:*
Please select one option
If job related, have you made a report of your accident to your employer?
Has this condition
Does this condition interfere with
Has this condition occurred before?
Have you seen other doctors for this condition?*
Please select at least one option
Place an X on the image below, where you feel pain, numbness or tingling:

Experience with Chiropractic

Have you been adjusted by a chiropractor before?*
Please select at least one option
Has any adult in your family seen a Chiropractor?
Has any child in your family seen a Chiropractor?

Awareness of Chiropractic Principles

Were you aware that...

Doctors of Chiropractic work with the nervous system?
The nervous system controls all bodily functions and systems?
Chiropractic is the largest natural healing profession in the world?
If Chiropractic care starts at birth, you can achieve a higher level of health throughout life?

Goals for my Care

People see chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Please check the type of care desired so that we may be guided by your wishes whenever possible.

Please check the type of care desired so that we may be guided by your wishes whenever possible.
Medications I Now Take:

Health Habits

Do you exercise regularly?
Do you wear

Health Conditions

Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

Health Conditions:


Are you pregnant?
Are you nursing?
Are you taking birth control?
Do you experience painful periods?
Do you have irregular cycles?
Do you have breast implants?

Authorization for Care

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Who should receive bills for payment on your account?

Emergency Contact

My Health Insurance

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


Please let us know what you are currently doing to encourage optimal health:

Things I do currently to support my health include:
Please indicate which of these you do/have on a consistent basis:

Initial Consultation Form

Overall frequency of complaint
If yes, please select the amount below that you feel your symptoms increase at work:

Pediatric Health History Form

Please tick the purpose for your child's visit

Present Health Concerns

Is this problem
Does this interfere with the child's sleep?
Daily routine?
Is this becoming worse?
Often seemingly unrelated symptoms can manifest as other health concerns. Please tick if your child has had any of the following

Birth History

Was your child's birth
Was the birth considered
Was child born
Assistances used during delivery
Was labour
Were medications or epidurals given to the mother during birth?
Is there anything else we need to know about the birth

Growth & Development

At what age did the child:

Does your child sleep

Surgical History

Has the child had any surgeries?

Pediatric Health History Form

Family Health History:

Please note any health problems (ie: cancer, hereditary conditions, diabetes, heart disease) that are present in:

Physical Stressors:

Since problems that chiropractors look for and detect can be related to many types of stressors, the following information is also very important to us.

Any evidence of birth trauma to the infant?
Is a school backpack used?
Is it

Chemical Stressors:

During the mother's pregnancy:

Is the diet organic?
Do you use 'green products' in your home for cleaning?
How often do they receive processed foods, white sugar, gluten (flour), dairy in their diet?

Psychosocial Stressors:

Thank you for completing this form. If you have anything to add below, please add notes which can then be discussed with the doctor. If there are any other questions or concerns which you have, please discuss with the doctor.

Automobile/Personal Insurance Accident or Work Comp Questionnaire

Information about the Accident / Present Injury

Did you require post-accident hospitalization?
Before the injury were you capable of working on an equal basis with other your age?
Are your work activities restricted as a result of this accident?
Since this injury are your symptoms are:

Insurance Information

Driver of other vehicle (if any):

Driver of vehicle in which you were injured (if applicable):

Outcome Assessment

Check symptoms you have noticed since the accident:

Using the scale below for reference, please answer the following questions as accurately as possible

Activities of Daily Living

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

Going from Sitting-to-Standing
Climbing Stairs
Extended Computer Use
Getting Dressed
Lift Children/Groceries
Sexual Activities
Static Sitting
Static Standing
Yard Work
On average, how many hours do you spend sitting per day?

Thank you for taking the time to fill out this form.




Please do not submit any Protected Health Information (PHI).

Office Hours


8:00 am - 12:00 pm

2:00 PM - 6:00 pm


2:00 pm - 6:00 pm


8:00 am - 12:00 pm

2:00 pm - 6:00 pm


8:00 am - 12:00 pm

2:00 pm - 6:00 pm


By Appointment Only