KIDS HISTORY FORM -

2. PLEASE FILL OUT COMPLETELY

* Indicates required field

Child's Name *

First

Last

Date of Birth *

Phone Number *

Cell Phone Provider for APPT. Reminders: *

Email *

Parent / Guardian's Name(s) *

Address: *

Line 1

Line 2

City

State

Zip Code

Country

What office are you looking for an appointment in? *

Clinton Princeton

If you heard about us from a friend or other practitioner, please give us 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 CARRIER *

POLICY NUMBER *

GROUP NUMBER *

NAME OF PRIMARY INSURED *

PHONE NUMBER OF INSURANCE *

PRIMARY INSURED DOB *

ZIP CODE OF INSURANCE COMPANY *

Give us the picture, help Dr. Jodi to get to know your child:

Names and Ages of Siblings: *

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

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

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

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? *

What changes does your child need to improve their health? *

Comments / Other: *

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

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

Health History
The more information we have to understand how stress is effecting your child, the more we will know how to serve them optimally.

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 any serious illness or disease your child has had, include current and past illness. *

Please list any broken bones, torn ligaments, sprains or strains your child has experienced. Include location, date and how it happened. *

How would you describe your child's diet? What did your child have for dinner last night? BE DETAILED HERE. *

When was your child's last physical 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? *

How often does your child sit in front of a tv? Computer? Other screen? How many hours a day? *

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

Has your child experienced any significant loss or challenges? *

Which daily household items does your child come into contact with that are NOT natural / organic? *

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

Are there foods that your child absolutely stays away from? If so, please list foods and reasons: *

Please list all allergies, common ailments, aches and pains 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? *

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

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? *