Dr.

Lee Smith PEDIATRIC INTAKE FORM All Boca Chiropractic

Child's Name: Parent's Name:

Address: City, Zip:

Home Phone: Parent's Work Phone:

Parent's Cell Phone: SS#:

Child's date of birth: Referred by:

E-mail address:

Pediatrician Name & Phone:

All of the questions below are regarding your child. Circle the appropriate answer.
If yes, please explain:
Currently under care of a physician: Y N
If yes, what & when:
Previous surgery: Y N
If yes, please list:
Currently taking medications: Y N

Takes a multi-vitamin: Y N

Difficult birth: Y N
forceps? Y N
C-section? Y N
breach/cephalic? Y N
home birth? Y N
mother given drugs? Y N
induced labor? Y N

Has allergies (medication, environmental, If yes, please list:

food, etc.): Y N

Frequent colds (more than 2x per yr): Y N

If frequently, how often?
Has/had an ear infection: Y N

Ever been checked for scoliosis: Y N If yes, has scoliosis: Y N

Dr. Lee Smith PEDIATRIC INTAKE FORM PAGE 2 All Boca Chiropractic

As an infant/toddler did/does your child ever do any of the following:

Breastfeed on 1 side only: Y N

Tug at his/her ears: Y N

Have uneven butt cheeks: Y N

Delayed speech skills: Y N

Delayed motor skills: Y N

Experience reflux: Y N

Fall: Y N

If your child is older than 3, does/did your child ever do any of the following:

Experience headaches: Y N
If yes, where?
Have "growing pains" Y N

Difficulty focusing: Y N
If yes, please explain:
Has a learning disability: Y N

Fall: Y N

Please list all of your child's activities:

Consent for examination/treatment: I authorize the performance of an examination and treatment

of my child by Dr. L. Lee Smith.

Parent Signature Date

Consent for diagnostic x-ray: I authorize the peformance of a diagnostic x-ray examination
of my child which Dr. L. Lee Smith may consider necessary
or advisable in the course of examination and treatment.

Parent Signature Date