Van Family Chiropractic

Erin Van Veldhuizen, D.C., C.C.C.N.

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Online Child Intake Form

Intake

Child's Personal Information
Child's Name(required)
Parent/Guardian Name
Age(required)
Date of Birth
Social Security Number
Address 1
Address 2
City
State
ZIP
Home Phone
Work Phone
Cell Phone
Email(valid email required)
Employer
Sex
How Many Siblings
Sibling Names & Ages
Referred to Dr. Erin by
Purpose of Visit
Have you seen another doctor for this?
If Yes, describe treatment
Health History
Ear Infections Scoliosis Seizures Chronic Colds Digestive Problems Colic Asthma Allergies ADD/ADHD Recurring Fevers Bed Wetting Car Accident Sports Injury Growing Pains other Pain Temper Tantrums Difficulty Sleeping Diabetes Slow Physical Development Slow Mental Development
Please list any and all traumas or injuries child has experienced:
Has your child fallen head first from a high place?
Please list & describe any surgeries your child has had:
Number of medications or Antibiotics child has taken in the past year:
Number of medications or Antibiotics child has taken in their lifetime:
Please describe child’s normal diet on a daily basis:
Does your child do any physical activity? Please describe what type & how often:
Has your child had vaccinations?
If Yes, was there an adverse reaction?
Prenatal & Birth History
Complications during pregnancy?
If Yes, please describe
Ultrasounds during pregnancy?
if yes, how many & during which month?
Any medications taken before or during delivery?
Alcohol/Cigarettes/Drugs during pregnancy?
Was your baby full-term?
Location of birth:
How long was the labor?
Epidural?
Forceps?
Vacuum Extraction?
VBAC?
C-Section?
If Yes, emergency or planned
Any complications with delivery?

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Dr. Erin Van Veldhuizen
Office Information

Location & Hours
4100 McEwen Rd.
Suite 130
Dallas, TX, 75244
Phone: (214) 295-9671
Email Dr. Erin
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Van Family Chiropractic

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