BABY HISTORY FORM -

2. PLEASE BE AS DETAILED AS POSSIBLE SO THAT WE CAN BEST SERVE YOU.

* Indicates required field

Child's Name *

First

Last

Date of Birth *

Phone Number *

Cell Phone Carrier for Text Reminders *

Email *

Parent / Guardian's Name(s) *

Where would you like to see us: *

Clinton Princeton

Address: *

Line 1

Line 2

City

State

Zip Code

Country

Names and Ages of Siblings: *

Is there anyone else at home that would like an appointment with Dr. Jodi at this time? *

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 *

Let us know how we can help:

Please list all health issues that your child experiences: *

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? *

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

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

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

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

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

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? *

Chemical Stresses:
Everyday chemicals can create tension in the body; causing great health issues.

Physical Stresses
The average child falls 2500 times in their first five years of life. There is up to 90 pounds of pressure put on the spinal cord at birth. These stresses add up and create all kinds of health issues!

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

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? *

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. *

How often do you burp your baby? Please describe what you do. (This is important to a chiropractor!). *

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

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