Dr. Vance Kruszewski & Dr. Janis Noseworthy
189 Dykeland Street, Suite 5, Wolfville, Nova Scotia B4P 1A3
Tel: (902) 542-9355 Fax : (902) 542-2838
PEDIATRIC ENTRANCE FORM
Child’s NameDate
Parents’ Names
Marital status of parents______
Are you legally entitled to consent to this child’s healthcare? ______YES ______NO
Siblings’ Names (ages)
Address
CityProv..Postal Code
DOBAgeTel ______
Referred By
Has your child ever received chiropractic care?____YES_____NO
If yes, previous doctor’s name and date of last visit______
Name of Medical Doctor ____
Date of last doctor visit and reason __
Present Health Complains/Concerns
Major______
Minor__
When did this problem begin?______
Is this problem (circle) occasional frequentconstantintermittent
Does this problem radiate? ___YES ____NO If yes, where?
What makes this worse?______
What makes this better?______
Is the problem worse during a certain time of the day? ____YES ____NO
If yes, when?
Does this interfere with the child’s Sleep Eating Daily Routine
Is this becoming worse?_____
Other professionals seen for this condition______
Results with that treatment______
Often seemingly unrelated symptoms can manifest as other health concerns:
(please circle if your child has had any of the following)
HeadachesLoss of tasteWeight gainUpper back pain
DizzinessLight sensitivityDental problemsNeck pain
FaintingFace flushedFeversLow back pain
IrritabilityBronchitisChest pressureStiffness
DepressionPneumoniaBreast PainReduced Mobility
Loss of balanceDifficulty breathingFrequent coldsNumbness in leg(s)
Loss of concentrationShortness of breathSinus congestionNumbness in feet
Loss of memoryAsthmaSore throatNumbness in hand(s)
Ear buzzingUrinary problemsEar infection/painWeakness
Poor coordinationConstipationAllergiesMuscle cramps
Vision changesDiarrheaHeartburnSleeping problems
Loss of smellWeight lossBloatingGas
Other?
History of Birth
What was the child’s gestational age at birth?weeks
Birth Weight_lbsozBirth Length ______inches
Was your child born (circle)at homein a birthing centerin a hospital
Was the birth considered(circle)medicalmidwife
What was the duration of the labour and birth?hours
Was the child borncephalic (head first)breech (feet first)?
Were there any complications?YESNO
If yes, please explain_
Please circle any assistance which was used during the birth
ForcepsVacuum extractionC-section Episiotomy
Was labour (circle)spontaneous or induced
Were any medications or epidurals given to the mother during birth?YESNO
If yes, what was given?__
Apgar score (if known):at birth/10after 5 minutes/10
Growth & Development
Was the infant alert and responsive within 12 hours of delivery?YESNO
If no, please explain__
At what age did the child
Respond to soundFollow an object
Hold up headVocalize
Sit aloneTeethe
CrawlWalk
Do you consider the child’s sleeping pattern normal?YESNO
If no, please explain______
Family Health History
Please note any health problems
Mother’s family
Father’s family______
Siblings
Since problems that chiropractors look for can be related to many types of stressors, the following information is also very important to us:
Physical Stressors
Any trauma to the mother during pregnancy? (falls, accidents, etc.)YESNO
Please explain
Any evidence of birth trauma to the infant? (Please check)
Bruising Stuck in birth canal
Respiratory depression Odd shaped head
Fast or excessively long birth Cord around neck
Any falls from couches, beds, change tables, etc.?YESNO
If yes, please provide details
Any traumas resulting in bruising, cuts, stitches or fractures?YESNO
If yes, please provide details
Any hospitalizations or surgeries?YESNO
If yes, please provide details
Any sports played? __
Is a school backpack used?YESNO
If so, is itheavy orlight
Chemical Stressors
Was the child breast fed?YESNO
If yes, how long?
Formula introduced at what age?What formula?______
Introduction of cow’s milk at what age?__
Began solid foods at what age?Types of foods?____
Any food or juice intolerance?YESNO
Type of intolerance?______
During pregnancy did the motherSmoke?YESNOHow much?______
Drink?YESNOHow much?______
Any illnesses during the pregnancy?YESNO
If yes, please explain______
Any supplements taken during pregnancy?YESNO
If yes, please list ____
Any Ultrasounds?YESNO
How many and reasons for being done?
Any invasive procedures during pregnancy (amniocentesis,surgery, etc.)?YESNO
If yes, please explain_
Any pets at home?YESNOList
Any smokers in the home?YESNO
Vaccinations and age given______
Any negative reactions?YESNO
Please explain______
Any antibiotics given?YESNO
Reason______
Psychosocial Stressors
Any difficulties with lactation?YESNO
Any problems with bonding?YESNO
Any behavioral problems?YESNO
Any night terrors, sleepwalking, difficulty sleeping?YESNO______
Age when child began daycare ______
Average number of hours of TV per week
Average number of hours of computer use/gaming/etc. per week______
Do you feel that your child’s social and emotional development is normal for their age? YES NO
If no, explain ______
Additional Comments
______
Signature:Date:_