Pediatric Health History Form

Pediatric History Form

  • Pediatric Health History

    In order to provide you 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.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Parent/Guardian Contact Info

  • Your email will NOT be shared with any third parties, and is used for occasional office announcements and appointment reminders
  • Current Complaints

  • (If you have no health concerns, please type wellness.)
  • MM slash DD slash YYYY
  • (If gradual, please state gradual.)
  • (1 is mild and 10 is severe)
  • MM slash DD slash YYYY
  • Medical History

  • (Please list dosage and amounts, etc. If none, please state none.)
  • (Please list what condition, dosage, and frequency.)
  • Have child ever:

  • Please check all that apply:

  • Please identify how your current conditions are affecting your ability to carry out activities that are routinely part of your life.

  • Please select the number that best indicated the level of pain the child is experiencing. Please rate only the problem that bothers him/her most.

  • How close to "0" does your pain get?
  • How close to "10" does your pain get?
  • Family Health History

    Please select which family members have/have had the following conditions:
  • 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.


2:45pm - 6:00pm

9:15am - 12:00pm
2:45pm - 6:00pm

2:45pm - 6:00pm

8:30am - 12:00pm
2:45pm - 6:00pm


8:45am - 10:00am


Scoles Family Chiropractic

7555 Oak Ridge Hwy
Knoxville, TN 37931

(865) 531-8025