BABY HISTORY FORM -

Please be as detailed as possible. The more information we have, the more we know how to help you! If it works better for you, CLICK HERE to download history form and print out.

* Indicates required field

Child's Name *

First

Last

Date of Birth *

Date of 1st visit: *

Phone Number *

Cell Phone Carrier for Text Reminders *

Email *

Address: *

Line 1

Line 2

City

State

Zip Code

Country

Parent / Guardian's Name(s) *

Names and Ages of Siblings: *

Who would you like an appointment with? *

Dr. Jodi Clinton Dr. Jodi Princeton I'm not sure, please call me.

If you heard about us through a friend / family / practitioner, please share their name so that we can thank them! *

We will check your insurance for you. Please disregard if you have an HMO or no insurance.

INSURANCE COMPANY *

PRIMARY INSURED *

ZIP CODE OF INSURANCE *

POLICY NUMBER *

PRIMARY INSURED DOB *

GROUP NUMBER *

INSURANCE PHONE NUMBER *

Why are you seeking treatment for your child in our office at this time? *

What do you hope for your child to get out of their experience at LightSource Chiropractic? *

On a scale of 1-10, 10 being your child's BEST possible health and 1 being VERY SICK, where do you feel your child is at today? *

PLEASE LIST YOUR CHILD'S HEALTH CARE PROVIDERS AND WHAT YOUR CHILD SEES THEM FOR *

Do you or your spouse have any fears / concerns about your child seeing Dr. Jodi? *

Please describe your child's personality, nature, and anything that makes them unique. *

Your child's health history:

Your child's first visit with us will include a thorough health history and detailed spinal exam. The more information we have to understand how stress is effecting your child, the more we will know how to serve them optimally. Please be thorough with this form, and we thank you in advance for your provocativeness with your child's wellness.

Please tell us about your baby's diet: *

I am nursing exlusively I am nursing and we supplement with formula (let us know what kind of formula in comments field) I am using formula, no nursing My baby is on solids at this point

Types of formula or solids? *

Please list any surgeries your child has had, include date and reason: *

Is your child vaccinated? If so, has your child had any adverse reactions or symtoms following their vaccines? *

Please tell us about your child's birth history. Include where they were born, who your practitioner was, any intervention, drugs, epidurals, surgery, etc. *

Please list all medications and supplements your child is currently take, amount and what they take them for: *

Please tell us about your child's sleeping patterns: *

Please list any injuries your child has experienced. Let us know how it happened and what the treatment for it was. *

When was your child's last check up and what did you learn about your child? *

Has your child ever been to a chiropractor? If so, when was their last adjustment and with whom? What did you love most about their care? Least? If your child has never seen a chiropractor, why not? *

Why does NOW feel like a good time for your child to receive care with Dr. Jodi? *

Is there anything else you would like us to know about? *

Please list all health issues that your child experiences: *

Who are your child's current health care providers? What do you see them for? *

What are the TOP THREE ATTRIBUTES you look for in a family practice for your family? *

Our experience shows that when one family member begins chiropractic care in our office, siblings and parents often start with us too. Is there another family member you would like us to check at this visit? *

LIGHTSOURCE CHIROPRACTIC