Align Spine Chiropractic & Wellness

10 Union St #2D,
Natick, MA 01760

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(508) 545-6789 Schedule your visit

Home
Patient Center
About Us
Services
Blog
Contact Us
- Appointment Request

(508) 545-6789 Schedule your visit

Home

Patient Center

Online Forms

(Pediatic) Intake from Birth to 12 Years

(Pediatic) Intake from Birth to 12 Years

Child's Name*

Child's date of birth (DOB) *

Parent or Guardian Name *

Cell Phone

Home Phone

Email *

Street Address, City, Zip code

Health insurance carrier

ID Number Group Number

Subscriber"s name DOB

Pediatrician and group name *

PRENATAL/BIRTH HISTORY

Is your child adopted?

No Yes

Smoke, use drugs or consumed alcohol during gestation

Medication taken during gestation, What and Why?

Ultrasound used during pregnancy

Delivering Practitioner

Place of birth

Type of birth

Pain medication used

Was labor induced?

If yes, why?

Delivery position

Birth Trauma

Doctor assisted Twisting and or pulling Vacuum extraction Forceps

Newborn trauma procedures tests

APGAR score

Does your child have a misshapen head?

Purple markings on face

BABY/TODDLER AGES 0-3

Breast Fed

How long was baby breast fed?

One sided breastfeeding preference

Feeding difficulties

Cry or Irritability with diaper change

Frequent spitup after feeding

Formula fed At which age

Vaccinations

Have any of the following occurred

Allergies Earaches infections Arm leg pains Car accident Fall from changing table Fall from crib Frequent falls Tumble downstairs Frequent Crying Colic Repeated illness infections Plays in Johnny Jumper Frequent fevers Frequent diarrhea Stomach pains Rapid weight loss gain Sleeping problems Reaction to vaccines

Other conditions

CHILDREN AGES 4-12

Have any of the following occurred

Allergies Stomach pains Frequent diarrhea Frequent vomiting Constipation Earaches infections Arm leg pains Auto accident Tumble downstairs Fall from tree Fall on playground Fall off bicycle Sleeping problems Repeated infections colds Rapid weight loss gain Reaction to vaccines Scoliosis Asthma Bedwetting Broken bones Hyperactivity Aspergers Syndrome Autism Learning difficulties

Other conditions

Vaccinations

GENERAL

How would you rate your child's diet?

When and how did the symptoms begin?

Describe any signs or symptoms.

Do the symptoms affect activity or concentration levels?

What activities or sports does your child participate in?

Fluoridated water

Number of hours your child sleeps

Sleep Quality

Any vitamins or supplements

Recent antibiotics regime? If so, when and for what?

Is your child taking any other medications?

Surgeries

I understand that I responsible for verifying my Chiropractic benefits with my insurance company prior to my initial visit. *

I understand that I am responsible for keeping my appointments. I am aware that if I fail to show up for a scheduled appointment, I agree to pay the $50 no show fee.** *

Please do not submit any Protected Health Information (PHI).

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Align Spine Chiropractic & Wellness

10 Union St #2D,
Natick, MA 01760 US

Monday:

9:00 am - 12:30 pm

2:30 pm - 6:00 pm

Tuesday:

7:30 am - 12:30 pm

2:30 pm - 4:00 pm

Wednesday:

9:00 am - 12:30 pm

2:30 pm - 6:00 pm

Thursday:

7:30 am - 12:30 pm

2:30 pm - 4:00 pm

Friday:

7:30 am - 12:00 pm

Saturday:

Closed

Sunday:

Closed

CONTACT US

We hope to see you soon

Name*

Email *

Phone *

Comments

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Align Spine Chiropractic & Wellness

10 Union St #2D
Natick, MA 01760, US

(508) 545-6789

[email protected]

10 Union St #2D,
Natick, MA 01760

(508) 545-6789

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