0-3 Years Old Health Record Forms You are here: Home - Online Forms - 0-3 Years Old Health Record Forms

To download a PDF of the 0-3 year old health form to print and fill out, click here.

Or you can fill out the online form below:

About the Child

NAME:
ADDRESS:
CITY:
STATE/ ZIP CODE
Home Phone
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
GENDER:
WEIGHT:

About the Parent

PARENT/ LEGAL GUARDIAN NAME:
PARENT/GUARDIAN ADDRESS:
PARENT/GUARDIAN CITY:
PARENT/GUARDIAN STATE/ZIP CODE
PARENT/GUARDIAN HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
EMPLOYER NAME
EMPLOYER ADDRESS
EMPLOYER CITY
EMPLOYER STATE/ZIP CODE
WORK PHONE
POSITION:
INSURANCE COMPANY:
INSURED'S NAME:
INSURED'S SSN:
INSURED'S DATE OF BIRTH:

Vaccinations/Medications

HAVE YOU CHOSEN TO VACCINATE YOUR CHILD?
IF YES, CHECK ALL THAT YOUR CHILD HAS RECEIVED:
DESCRIBE ANY AND ALL REACTIONS TO VACCINE(S):
LIST PRESCRIPTION MEDICATION TAKEN:

Chiropractic Experience

WHO REFERRED YOU TO OUR OFFICE?
HAVE YOU SEEEN OR HEARD OF OUR OFFICE BECAUSE OF (CHECK ALL THAT APPLY):
HAVE YOU EVER BEEN ADJUSTED BY A CHIROPRACTOR BEFORE?
IF YES, WHAT WAS THE REASON FOR YOUR VISIT(S)?
DOCTOR'S NAME:
APPROXIMATE DATE OF LAST VISIT:

Reason for this Visit

THE REASON FOR THIS VISIT IS...
EXPLAIN:
IS THE PURPOSE OF THIS VISIT RELATED TO
EXPLAIN
WHEN DID THIS CONDITION BEGIN?
HAS THIS CONDITION:
DOES THIS CONDITION INTERFERE WITH:
EXPLAIN INTERFERENCE
HAS THIS CONDITION OCCURRED BEFORE?
PLEASE EXPLAIN:
HAVE YOU SEEN OTHER DOCTORS OR CHIROPRACTORS FOR THIS CONDITION?
IF YES, DOCTOR'S NAME:
TYPE OF TREATMENT:
RESULTS:

Prenatal History

DURING THE PREGNANCY, DID YOU USE:
IF YES, EXPLAIN:
LOCATION OF BIRTH:
DESCRIBE YOUR DELIVERY:
PLEASE EXPLAIN DELIVERY
HOW LONG WAS THE LABOR FROM THE FIRST REGULAR CONTRACTIONS TO THE BIRTH?
HOW LONG WAS THE 2ND STAGE (THE PUSHING PHASE) OF LABOR?
EXPLAIN ANY COMPLICATIONS THAT OCCURRED DURING DELIVERY:
DID YOU EXPERIENCE ANY ILLNESS(ES) WHILE PREGNANT?
IF YES, PLEASE EXPLAIN
PLEASE DESCRIBE ANY DISABILITIES:
BIRTH WEIGHT:
BIRTH LENGTH:

APGAR Scores

AT 1 MIN
AT 5 MIN (1)
ULTRASOUND DURING PREGNANCY:
NUMBER:
DID YOU BREASTFEED THE BABY?
IF YES, HOW LONG?
DID YOU FORMULA FEED THE BABY?
IF YES, HOW LONG:

At what age did you introduce:

SOLIDS:
COW'S MILK:
ARE YOU AWARE OF ANY FOOD OR JUICE ALLERGIES OR INTOLERANCES?
HAS YOUR CHILD EVER TAKEN ANTIBIOTICS?
IF YES, EXPLAIN
HAS YOUR CHILD EVER BEEN HOSPITALIZED?
IF YES, WHAT WERE THE CIRCUMSTANCES?

THE NATIONAL SAFETY COUNCIL REPORTS APPROXIMATELY 50% OF CHILDREN FALL HEAD FIRST FROM A HIGH PLACE DURING THEIR FIRST YEAR OF LIFE (I.E. BED, CHANGING TABLE, STAIRS, ETC.)

WAS THIS THE CASE WITH YOUR CHILD?
IF YES, PLEASE EXPLAIN FALL:
HAS YOUR CHILD EVER BEEN IN A CAR ACCIDENT?
IF SO, PLEASE EXPLAIN:
HAS YOUR CHILD EVER HAD SURGERY?
LIST ALL SURGERIES:
DOES YOUR CHILD HAVE DIFFICULTY INTERACTING WITH OTHERS?
IF YES, EXPLAIN DIFFICULTIES
HAVE YOU OR ANYONE ELSE NOTICED THAT YOUR CHILD IS NERVOUS, TWITCHES, SHAKES OR EXHIBITS ROCKING BEHAVIOR?
PLEASE EXPLAIN.
WHAT CHANGES, IF ANY, IN YOUR CHILD'S HEALTH OR BEHAVIOR WOULD YOU LIKE ACCOMPLISHED?

Child's Health History

Instructions:�Please check each of the diseases or conditions that the child now or has had 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.

CHECK ALL THAT APPLY:

Notice of Privacy Policy

Protecting the privacy of your personal health information is important to us. Disclosure of your protected health
information without authorization is strictly limited to defined situations that include emergency care, quality assurance
activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment,
payment or practice operations will be made only after obtaining your consent.
� �- You may request restrictions on your disclosures.
� �- You may inspect and receive copies of your records within 30 days with a request.
� �- You may request to view changes to your records.
� �- In the future, we may contact you for appointment reminders, announcements and to inform you about our practice
and its staff.
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to
privacy regarding my protected health information. I understand that this information can and will be used to:
� �- Conduct, plan and direct my treatment and follow up with multiple healthcare providers who may be involved in that
treatment directly or indirectly.
� �- Obtain payment from third party payers.
� �- Conduct normal healthcare operations such as quality assessments and physician’s certifications.
I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also
understand that I can request, in writing, that you restrict how my personal information is used and or disclosed.

BY CHECKING THIS YOU AGREE THAT YOU HAVE READ AND UNDERSTAND ACTIVE FAMILY CHIROPRACTIC'S PRIVACY POLICY

Authorization for Care of a Minor

It is understood and agreed that the payments to the doctor for x -rays is for examination of x-rays only. The x-ray films will remain
the property of this office. They are kept on file where they may be seen at any time while I am a patient in this office. I understand
that all services are to be paid in full at the time of service, unless other arrangements have been made and agreed in writi ng.
I hereby authorize the doctors in this chiropractic office and whomever they may designate as their assistant to administer
chiropractic care, to work with my condition through the use of adjustments and procedures the doctor deems appropriate. I c learly
understand and agree that all services rendered me are charged directly to me and that I am personally responsible for paymen t. I
agree that I am responsible for all 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 if I suspend or terminate my care for any reason, any fees for
professional services rendered me will become immediately due and payable. I hereby authorize assignment of my insurance rig hts
and benefits (if applicable) directly to the provider for services rendered.
I authorize the use of this signature to allow the insurance companies to pay Active Family Chiropractic directly any amounts
payable as my assignment of benefits. I authorize the use of this signature on any insurance submissions.

I authorize the doctor in this chiropractic office to administer chiropractic care to work my condition through adjustments and procedures the Doctor deems appropriate.