(805) 665-3835
1522 State Street unit A, Santa Barbarba, CA
Phone (805) 665-3835
Pediatric Health History Form
Patient’s Name
Today’s Date
Address
Parent’s
City & State
Zip
Home Phone
Work Phone
Cell Phone
Birth Date
Age
Weight
Height/Length
Gender
M
F
Parents’ Names & Ages
Names & Ages of Siblings
Are the other members of your family Under Chiropractic Care?
Yes
No
Names & Ages of Siblings
How Did You Hear About Us?
Has your child ever been to a chiropractor before?
If so, when?
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Past Health History
How Much Birth Trauma Did Your Child Experience?
Long Delivery?
Difficult Delivery?
Induced Labor?
Hospital birth?
Forceps Used?
Caesarian Section?
Vacuum Extraction?
Breech/cephalic presentation?
Mother given drugs?
Vaccines within first 3 years of life?
Any conditions your child currently has or previously has had.
AIDS/HIV
Emphysema
Gout
Pinched Nerve
Tonsillitis
Arthritis
Cataracts
Heart Disease
Pneumonia
Scarlet Fever
Asthma
Chemical Dependency
Hepatitis
Polio
Tumors or Growths
Anemia
Chicken Pox
Liver Disease
Pacemaker
Typhoid Fever
Anorexia
Cold/Flu
Measles
Parkinson’s Disease
Ulcers
Appendicitis
Goiter
Herpes
Psychiatric Care
Vaginal Infections
Bulimia
Gonorrhea
High Cholesterol
Rheumatoid Arthritis
Vision Problems
Cancer
Epilepsy
Kidney Disease
Rheumatic Fever
Viral Infections
Bleeding
Fibromyalgia
Migraines
Prostate Problem
Tuberculosis
Breast Lump
Glaucoma
Multiple Sclerosis
Stroke
Whooping Cough
Bronchitis
Hearing Problems
Mumps
Suicide Attempt
Diabetes
Hernia
Osteoporosis
Tooth Problems
Ear Infections
Herniated Disc
Mononucleosis
Thyroid Problems
Other
Other
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Describe the prenatal care:
How long was delivery?
Did the delivery include
Hospital
Midwife
Doula
Do you know your baby’s APGAR Score?
Does your child experience any sleeping problems?
Yes
No
If so, please explain
Child’s sleeping posture
Stomach
Back
Other
Others
Describe your child’s diet
Please list any surgeries, traumas, fractures, etc.
Date
Describe/Treatment
Date
Describe/Treatment
Date
Describe/Treatment
Date
Describe/Treatment
Has Your Child Experienced Side Effects From Drugs and/or Surgery?
Exercise
Moderate
Daily
Sports
Weight Lifting
None
Others
Other
Daily Activity
Sitting- Hrs/Day
Standing- Hrs/Day
Physical Activity- Hrs/Day
Technology- Hrs/Day
Other
Habits
Coffee/Caffeine- Cups/Day
High Stress?
Reason for Stress
School
Physical
Mental
Emotional
Others
Others
Medications & Supplements
Please list all current medications, vitamins, and other dietary supplements:
Please list all past medications, vitamins, and other dietary supplements:
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Do your child experience any sleeping problems? (including nightmares)?
Yes
No
What is their sleeping posture
Side
Stomach
Back
What percentage of their food is
Organic?
Conventional?
GMO?
Processed/Packaged?
What percentage of their produce is from
Farmer’s Market?
Health Food Store?
Grocery Store (eg. Vons, Albertson’s, Ralph’s)?
What percentage is:
Frozen?
Canned?
Powder, Capsule, or Drink?
How often do they eat meat?
What kind of meat do they typically eat?
Family History:
Father’s Family
Heart Disease
Arthritis
Cancer
Diabetes
Other
Specify Others
Mother’s Family
Heart Disease
Arthritis
Cancer
Diabetes
Other
Specify Others
Current Health Condition
What is the reason for your child’s visit today?
Besides visiting our office today, what other steps are you taking to maximize their health and wellness?
If you are here for Pain or a Problem, when did it start?
Does it feel:
Sharp
Dull
Constant
Intermittent
What activities make your condition or pain better or worse?
Is condition worse during certain times of the day?
Is this condition interfering with their:
Work
Sleep
Daily Routine
Other
Others
Is this condition getting:
Worse
Better
The Same
What type of care have they already received for your condition?
Chiropractic
Massage
Medication
Surgery
Other
Others
Name of Doctor(s) who have cared for your child
Other Current Health Concerns
Neck Pain or Stiffness
Low Back Pain
Nervousness
Ringing / Buzzing in Ears
Headache
Hip or Groin Pain
Tension
Cold or Fever
Shoulder Pain
Leg Pain R L
Irritability
Fainting
Upper or Mid-Back Pain
Pins & Needles: Legs R L
Depression
Loss of Balance
Chest Pains
Numbness in Toes
Fatigue
Diarrhea
Rib Problems
High or Low Blood Pressure
Cold Sweats
Constipation
Arm or Hand Pain R L
Allergies
Face Flushed
Upset Stomach
Pins & Needles: Arms R L
Dizziness
Shortness of Breath
Numbness in Fingers
Sleeping Problems
Memory Loss
Other
Others
What Benefits of Chiropractic Care Would You Like to Achieve?
Relieve Pain Quickly
Recovery from Injury or Disease
Help My Child Resist Injury or Disease
Avoid Drugs and/or Surgery
Improve My Child’s Spinal & Nervous System Health
Live a Longer, Healthier, Happier Life
Live a More Vitalistic, Holistic Life
Improve My Performance in Physical Activities
Remain Active Longer
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1522 STATE ST, SANTA BARBARA, CA, UNITED STATES
Quick Links
About Us
Services
Community
Services
Physical Medicine
Physiotherapy and Rehab
Regenerative Medicine
Trigger Point Treatment
Chiropractic Adjustments
Enriched Plasma Therapy
Sarapin Injections
Quick Links
1522 State Street Santa Barbara, CA 93101
805.665.3835
ISChiroSB@gmail.com
Copyright © 2023 Inner Strength Medical and Wellness All Rights Reserved
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