Discover Chiropractic
151 North Sunrise Avenue
Roseville, CA 95661-4516
ph: 916.772.7722

Office Hours:
Mon & Wed: 8am – noon & 3pm – 6pm
Tues: 3pm – 6:30pm
Thurs: 8am – noon & 3pm – 6:30pm
Saturday: Once Per Month By Appt Only

Child Health History

ABOUT THE CHILD
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  5. Gender
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REASON FOR THE VISIT
  2. Is the purpose of the visit related to:
  6. Has this condition
  8. Does this condition interfere with
  11. Have you seen other doctors for this?
  16. Is your child currently taking medication?
  19. Has your child been vaccinated?
  21. * If you have chosen a modified vaccine schedule check the following vaccines given:
  23. Click here to view the Standard Vaccine Schedule.
MOTHER's PREGNANCY & LABOR
  1. During pregnancy did mother:
  2. .... take any medication
  5. .... smoke or consume alcohol?
  7. ..... experience any illness?
  11. Was labor chemically induced?
  13. Was labor doctor assisted?
  15. Was a C-Section performed
  17. Were forceps or vacuum extraction used?
  19. Did the delivery doctor pull or twist the baby during delivery?
  21. Was delivery premature?
  24. Check any of the following if the child experienced it immediately after birth.
CHILD's HEALTH HISTORY
  1. Please check each off the diseases or conditions that the child has now or has had in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis.
 

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