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We Create Healthy Families

Call us at (605) 275-5757 to make an appointment.

Pediatric

Pediatric Patient Intake Form









Male
Female












Existing Patient
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Another Provider
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CURRENT HEALTH CONDITIONS




Suddenly
Gradually
Post Injury


Yes No




Getting worse Imporoving Intermittent Constant Unsure





HEALTH HISTORY


No problems Epilepsy
Acid reflux Febrile Convulsions
ADD Fever
ADHD Foot flare
Arm or shoulder condition Headache
Asperger's Hearing difficulties
Autism Inability to thrive
Cerebral palsy Jaundice
Colic Seizures
Congenital anomalies Sleeping problems
Difficulty eating Speech difficulties
Difficulty walking Vision difficulties
Down's syndrome Torticollis
Ear infection (chronic) OTHER
Enuresis (bedwetting)

PREGNANCY & FERTILITY HISTORY

Please tell us all about your pregnancy.


Yes No




Yes No




Yes No




Yes No




Yes No




Yes No




Yes No




Yes No







LABOR & DELIVERY HISTORY




At home At a birthing center At a hospital Other




Natural vaginal birth Scheduled C-section Emergency C-section


Breech Induction
Pain meds Epidural
Episiotomy Vacuum extraction
Forceps Bruising
Cord around neck Fast or excessively slow birth
Odd-shaped head Respiratory depression
Stuck in birth canal




Single Twins Triplets






0 1 2 3 4 5 6 7 8 9 10


0 1 2 3 4 5 6 7 8 9 10



GROWTH & DEVELOPMENT HISTORY


Yes No




Yes No


Yes No






Yes No




Yes No




Yes No




Yes No




None, all developmental goals were met on schedule
Delayed response to sound Delayed normal apperance of teeth
Delayed ability to follow an object Delayed ability to crawl
Delayed ability to hold head up Delayed ability to walk
Delay ability to vocalize Unsure
Delayed ability to sit alone OTHER








No/Yes on a delayed or selective schedule/ Yes On schedule




Yes No




Yes No


Yes No


Yes No




Yes No




Attention issues Bedwetting
Sleep walking Stutter or stammer
Failure to maintain eye contact Unsure
Hearing issues Nervous tics


Yes No






Yes No




Mostly whole organic foods Pretty average High amount of processed foods

HEALTH GOALS FOR YOUR CHILD







Resolve existing condition Overall wellness Both

CHIROPRACTIC HISTORY


Yes No





Pain Relief Physical Therapy & Rehab Nutritional Subluxation-based Other


Yes No




Pain Relief Physical Therapy & Rehab Nutritional Subluxation-based Other

INSURANCE & PAYMENT FOR CARE


Personal Insurance No Insurance Self Pay

Primary Insurance











CONSENT FORM& AUTHORIZATION

I hereby request and authorize the providers at Dr. Ashley Family Chiropractic to administer care as they deem necessary to my dependent minor child. This authorization also extends to include diagnostic imaging, laboratory and other testing at the doctor’s discretion. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to my child are charged directly to me and that I am personally responsible for payment at the time services are rendered.





As of today’s date, I have the legal right to select and authorize health care service for the minor child named above. If applicable, under the terms and conditions of my divorce, separation, or other legal authorization, the consent of a spouse, former spouse, or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify this office.