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Services
Meet The Doctors
Classes
- Calendar
Corporate
- Health Talk Topics
- Why Invest
Patient Education
Your First Visit
Contact
Book Appt

Child Intake Form

Health From Within / Child Intake Form

Child Intake Form

1 Patient Info

2 Guardian Info

3 Symptoms

4 Birth and Growth History

5 Past Treatments

6 Consent

Patient Name*
First Last
Gender*
- Male
- Female
Child's Date of Birth*
Date Format: MM slash DD slash YYYY
Child's Height*
Child's Weight*
Pediatrician's Name
First Last
Pediatrician's Phone

Guardian Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is the primary reason you are contacting us regarding your child?*
Please check off your chief concerns, if any, with your child's health*
- Headaches/Migraines
- Allergies
- Chest/Rib Pain
- Dizziness
- Ear Aches
- Asthma
- Frequent Colds/Flu
- Heartburn/Reflex
- Low Energy/Fatigue
- Weight Gain
- Loss of Memory
- Excess Gas/Bloating
- Multiple Sclerosis
- High Cholesterol
- Bladder Problems
- Digestive Problems
- Neck Pain
- Shoulder Pain
- Arm Pain
- Elbow Pain
- Wrist Pain
- Scoliosis
- Low Back Pain
- Mid Back Pain
- Disc Problems
- Insomnia
- Ringing/Buzzing in Ears
- High Blood Pressure
- Low Blood Pressure
- Fibromyalgia
- Shortness of Breath
- Cancer
- Heat Condition
- Kidney Disease
- Hip Pain
- Leg Pain
- Knee Pain
- Ankle Pain
- Muscle Stress
- Constipation
- Hyperactivity
- Arthritis
- Depression
- Bed Wetting
- Menstrual Problems
- Thyroid Trouble
- Circulatory Problems
- Nausea
- Vascular Disorder
- Immune System Disorder
- Mood Swings
- Chemical Stress
- Physical Stress
- Emotional Stress/Anxiety
- Attention Disorders
- Sciatica
- Numbess/Tingling
- Vertigo
- Ulcers
- Autoimmune Disease
- Diabetes
- Swollen Ankles
- Skin Conditions/Acne
- Diarrhea
- Urinary Difficulty
- Sinus Trouble
- Osteoporosis
Date of Onset*
Onset Speed*
- Sudden
- Gradual
- Associated with an event
Duration of condition/episode*
- Minutes
- Hours
- Days
- Months
- Years
Pattern of problem*
- Constant
- Intermittent
- Occasional
- Cyclical
Initiating Factors
Aggravating Factors
Relieving Factors
How does the problem affect your child's body and everyday activities?
Please use this space to include any other relevant details regarding the conditions cited above.

Hospital/Birthing Center*
- Home
- Medical
- Midwife
Duration of gestation (in weeks)*
Was the birth assisted?*
- Yes
- No
If yes, how?
- Forceps
- Vacuum Extraction
- C-Section
- Induced Labor
Were medications given to the mother at birth?*
- Yes
- No
If yes, what medications?
Duration of birth
Was the delivery normal?*
- Yes
- No
If no, what complications were there at birth?
APGAR at birth
APGAR after 5 minutes
Birth weight
Birth length
Growth and Development
Was the infant alert & responsive within 12 hours of the delivery?*
- Yes
- No
If no, elaborate
At what age did the child:
Respond to sound:
Follow an object:
Hold up head:
Vocalize:
Sit alone:
Teethe:
Crawl:
Walk:
Do his/her sleeping patterns seem normal?*
- Yes
- No
Describe any health problems that exist on the mother's side of the family? (e.g. Cancer, Diabetes etc.
The father's side?
Do the child's siblings have any health problems?*
- Yes
- No
If yes, describe:
The following information is very important because many of the problems that chiropractors work with are caused by stressors.

Chemical Stressors
During pregnancy, did the mother smoke?*
- Yes
- No
- Third Choice
Drink alcohol?*
- Yes
- No
Take supplements/vitamins?*
- Yes
- No
Take drugs?*
- Yes
- No
If yes, what drugs?
Become ill?*
- Yes
- No
If yes, ill how?
Receive ultrasounds?*
- Yes
- No
If yes, how many?
Receive invasive procedures (ie. anmiocentesis, CVS)?*
- Yes
- No
Was your child breast fed?*
- Yes
- No
If yes, how long?
At what age was formula introduced (include brand)?
At what age was cow's milk introduced?
Solid foods?
Did your child receive vaccinations?*
- Yes
- No
If yes, which ones?
Did your child react to them?
- Yes
- No
Has your child had antibiotics?*
- Yes
- No
If yes, how many courses has the child had so far & why?
Any pets at home?*
- Yes
- No
Any smokers at home?*
- Yes
- No
Psychological Stressors
Any difficulties with lactation?*
- Yes
- No
Any problems bonding?*
- Yes
- No
Does your child seem normal to you?*
- Yes
- No
Does the child have any behaviour problems?*
- Yes
- No
If yes, please describe:
Does your child have difficulties sleeping ( e.g. night terrors, sleepwalking, etc.)?*
- Yes
- No
If yes, specify:
Did your child go to daycare?*
- Yes
- No
If yes, from what age?
Average no. of hours of TV/Computer per week?*
Traumatic Stressors
Any evidence of trauma during birth?
- Bruises
- Odd shaped head
- Stuck in birth canal
- Fast and/or excessively long birth
- Respiratory Depression
- Cord around neck
Or describe any other birth trauma not listed above:
Any falls/accidents during pregnancy?*
- Yes
- No
Has the child had any major falls since birth?*
- Yes
- No
If yes, did the child need stitches or cause a fracture? Please describe:
Any hospitalizations?*
- Yes
- No
If yes please describe:
Does your child play sports?*
- Yes
- No
If yes, number of hours per week?
Age child began?
Weight of school backpack?
Approx. Hours spent at play per week?

Has your child been treated by a chiropractor for his/her condition or symptoms?
- Yes
- No
Name of Chiropractic Doctor
Date of most recent chiropractic visit*
Date Format: MM slash DD slash YYYY
Has your child undergone any other treatment for his/her condition or symptoms? Please elaborate if so.*

Consent Agreement*
- I agree that I have read the terms of our Informed Consent policy
Date*
Date Format: MM slash DD slash YYYY
Signature*

HOURS

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Tuesday
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Wednesday
4:00pm-7:00pm

Thursday
8:00am-11:00am & 4:00pm-6:00pm

Friday
8:00am-11:30am

DIRECTIONS

1818 Marron Road, Suite 103 Carlsbad, CA 92008

CONTACT

Phone: 760-385-8352 E-Mail: contact@healthfromwithinca.com

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