Infant Health History Form

Name: Scoles Family Chiropractic: Scoles Jennifer DC
Address: 7555 Oak Ridge Highway, Knoxville, Tennessee, 37931, United States
Telephone: 18655318025
Price range: $

Infant Health History

Infant Health History
In order to provide your child the best possible care, please complete this form in detail. (Fields marked with a red * are required and your form will not be submitted if these are left blank.) Once submitted, you will see "Thank you" on the next page.
Name*
First Last
Date of Birth*
Gender*
- Male
- Female
Father's Name*
Mother's Name*
Address - if parent is already a practice member, please skip
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent's Cell Phone Number
Parent's Email Address
How did you hear about our office?
- Google
- Facebook
- Location
- Friend (please specify who below)
- Event (please specify where below)
- Other (please specify below)
If event, friend or other, please specify how you heard about us:
Primary Care Physician
Insurance Company
Insurance ID Number
Baby's birth weight*
Baby's length*
Type of birth
Were forceps or vacuum used?
Complications during delivery? Was baby pre-mature or late?
Were medications used during labor and delivery? (Pitocin, Epidural, etc.)
Did baby receive any medications?
Did baby have jaundice?
- Yes
- No
Was light therapy used?
- Yes
- No
If male, was baby circumcised?
- Yes
- No
Any complications?
Has baby received any vaccinations?
- Yes
- No
Do you plan on doing full vaccine schedule?
- Yes
- No
How is nursing going?
Are you supplementing with formula?
How often is baby feeding?
How well is your baby sleeping?
Please list any medications and what they are for:
Please list all surgeries/accidents:
What is primary health concern? If he/she is here for wellness care, please say "wellness".*
What diagnostic tests and/or treatments have been received?
Please check any of the following that your baby has experienced:
- Allergies
- Colic
- Digestive Issues
- Ear Infections
- Latching Issues
- Tongue-Tie
- Torticollis
Family Health History
Please select which family members have or have had the following conditions:
Mother
- Allergies
- Asthma
- Constipation
- Ear Infections
- Back Trouble
- Arthritis
- Carpal Tunnel
- Disc Problems
- Fibromyalgia
- Headaches/Migraines
- High Blood Pressure
- Pinched Nerve
- Sciatica
- Scoliosis
- Sinus Trouble
- Sports Activities
- Stomach Trouble
- Deceased
Father
- Allergies
- Asthma
- Constipation
- Ear Infections
- Back Trouble
- Arthritis
- Carpal Tunnel
- Disc Problems
- Fibromyalgia
- Headaches/Migraines
- High Blood Pressure
- Pinched Nerve
- Sciatica
- Scoliosis
- Sinus Trouble
- Sports Activities
- Stomach Trouble
- Deceased
Grandparents
- Allergies
- Asthma
- Constipation
- Ear Infections
- Back Trouble
- Arthritis
- Carpal Tunnel
- Disc Problems
- Fibromyalgia
- Headaches/Migraines
- High Blood Pressure
- Pinched Nerve
- Sciatica
- Scoliosis
- Sinus Trouble
- Sports Activities
- Stomach Trouble
- Deceased
Siblings
- Allergies
- Asthma
- Constipation
- Ear Infections
- Back Trouble
- Arthritis
- Carpal Tunnel
- Disc Problems
- Fibromyalgia
- Headaches/Migraines
- High Blood Pressure
- Pinched Nerve
- Sciatica
- Scoliosis
- Sinus Trouble
- Sports Activities
- Stomach Trouble
- Deceased
Is there anything else you would like the doctors to know about?
Thank you for taking the time to fill out the health history, we look forward to seeing you soon.
Please make sure this submits properly. Areas with a red * must be completed, or it will not submit. Please correct and submit. Once submitted, you will see "Thank you" on the next screen.