PEDIATRIC PATIENT QUESTIONNAIRE

Transcription

1 2Dr. Stephanie Spiers DC, CACCP 9402 Towne Square Ave. Suite E Cincinnati, OH PEDIATRIC PATIENT QUESTIONNAIRE Child s Name: Nickname: Date: Parent(s) Name: Address: City: State: Zip: Home Phone: Cell: Parents Current Age: Birthdate: Siblings and ages: Have you or your child ever had chiropractic care before? Yes No If yes, please tell us the doctor s name: Were you pleased with your care? Yes No How did you find out about our office? Is your child receiving care from other health professionals? Yes No If yes please name them and their specialty Please list any drugs or medications your child is taking Please list any vitamins/herbs/homeopathic/other your child is taking Please list any allergies your child has WELLNESS PROFILE The human body is designed to be healthy. The primary system in the body which coordinates health and function is the nervous system. Your nervous system is surrounded and protected by the bones of the spine, called vertebrae. Many of the common health challenges that adults experience have their origins during the developmental years, some starting at birth. Layers of damage to the spine and nervous system occur as a result of various traumas, toxins, and emotional stress. The result may be misalignment to the spinal column and damage to the nervous system a condition called Vertebral Subluxation. Please answer the following questions to give us a better understanding about your child s state of wellness and factors which may be contributing to vertebral subluxation and impending your child s ability to heal. What signals has your child s body been communicating? Current Previous Asthma Respiratory Tract Infections Sinus Problems Ear Infections Tonsillitis Strep Throat Frequent Colds/Croup Recurrent Fevers

2 Eczema Rashes Allergies Food Sensitivities Digestive Problems Frequent Diarrhea Constipation Flatulence Headaches/Migraines Neck Pain Torticollis / Head Tilt Trouble feeding on One Side Back Pain Growing Pains Scoliosis Red, Swollen, Painful Joint Colic Frequent Crying Spells Failure to Thrive/Slow Weight Gain Slow or Absent Reflexes Asymmetrical Crawling or Gait Weight Challenges Bed Wetting Sleep Problems Night Terrors Tip Toe Walking Sensory Processing Issues Seizures Tremors / Shaking ADD / ADHD Autism / PPD CURRENT HEALTH Why have you decided to have your child evaluated by a Chiropractor? He/ She is continuing ongoing care from another chiropractor. I recently had my spine checked and understand the value in getting my child checked. I have concerns about his/her health and I m looking for answers. He/ She has a specific condition and I ve learned that chiropractic may be able to help. I want to improve my child s immune function. What condition brings your child to our office? When did the symptom first begin? How did the problem first start? Suddenly Gradually Post- Injury Is this condition Getting Worse Improving Intermittent Constant Not sure What makes the problem better? What makes the problem worse? Has your child ever had a similar condition? Yes No Please explain Has your child been treated for this problem before? Yes No Please explain Does your child eat well? Yes No Does your child have regular bowel/bladder movements? Yes No Has your child ever been checked for vertebral subluxations? Yes No Don t Know PRENATAL/BIRTH/INFANT PROFILE Did mother smoke during pregnancy? Yes No Did mother drink during pregnancy? Yes No Any illness of mother during pregnancy? Yes No If yes, please explain including treatment/medications/supplements List any drugs/medications (including over the counter) taken during pregnancy List any supplements taken during pregnancy Any exposure to ultrasound Yes No If so how many and what was the medical reason? Stress level of mother during pregnancy Difficulty conceiving? Childs birth was At home At a birthing center At a hospital

3 My obstetrician/midwife/family physician was Childs birth was Natural (no medications or interventions) Vaginal with interventions Induction Pain medication Epidural Episiotomy Vacuum extraction Forceps C-section Scheduled Emergency If birth was vaginal, was the baby presented: Head Face Breech How long was the labor from the first regular contractions to the birth? hours How long was the second stage (the pushing phase) of the labor? hours Was the baby born with any purple markings/bruising on their face or head? No Yes Any concerns about misshapen head at birth? Yes No How many weeks gestation was the baby at birth? weeks Was the baby ever administered to the NICU? Yes No If yes, how long and why? Please list any interventions/complications: Child s Birth weight Child s birth height Current weight Current height APGAR score at birth APGAR score after 5 minutes GROWTH AND DEVELOPENT Was your child alert and responsive within 12 hours of delivery? Yes No If no, please explain At what age did your child: Respond to sound Follow an object Hold head up Vocalize Sit alone Teeth Crawl Walk Please list any hospitalizations and surgeries Please list any major injuries, accidents and/or fractures your child has sustained in his/her lifetime Is/was your child breastfed Yes No If yes how long? Formula introduced at what age? What type? Introduced to cow s milk at age? Began solid foods at age Did you introduce cereal or grains within your child s first year? Yes No Did your child show any sensitivities to formula or breastfeeding (acid reflux, eczema, arching back)? Yes No Did your child spend a lot of time in any baby devices (bouncy seats, swings, bumbos, car seats, etc.)? Any pets at home? Yes No Any smokers at home? Yes No Has child received any antibiotics? Yes No If yes, how many times and list reasons Any difficulty with breast feeding? Yes No If yes, please explain Any difficulty with bonding? Yes No If yes, please explain Any behavioral problems? Yes No If yes, please explain Any night terrors, sleepwalking, or difficulty sleeping? Yes No If yes, please explain Age child began day care Average number of hours of TV per week

4 Does your child seem normal for their age? Yes No If no, please explain PHYSICAL TRAUMAS Has your child ever fallen from any high places? No Yes Has your child ever been involved in a motor vehicle collision? No Yes Has your child ever been seen on an emergency basis? No Yes Has your child ever broken any bones? No Yes Has your child ever had any previous hospitalizations? No Yes Has your child ever had any previous surgeries? No Yes Does your child ever use a tablet, computer, or video games? Never Rarely Daily Several hrs. /day Does your child watch TV? Never Rarely Daily Several hrs. /day Does your child exercise? Never Rarely Daily Several hrs. /day Does your child play contact sports? Never Rarely Daily Several hrs. /day Does your child carry a backpack? Never Rarely Daily Several hrs. /day Does it weigh less than 15% of their body weight? No Yes Does your child wear their back pack on two shoulders? No Yes Does your child show excessive or uneven shoe wearing out? No Yes Does your child wear custom orthotics? No Yes If yes, for what? CHEMICAL STRESSORS Have you chosen to vaccinate your child? No Yes, on a delayed schedule Yes, on schedule Reason for vaccination: Personal research Didn t have a choice It was recommended Reactions to vaccination: None Fever Diarrhea Rash Welt at injection site Fatigue Seizures Prolonged Cry Developmental Regression Other Does your child receive annual flu shots? No Yes (personal research Yes (MD recommended) Has your child been exposed to antibiotics? No Yes If yes, how many in the past 6 months? Reason: Has your child been exposed to medications, including OTC? No Yes If yes, which ones? If yes, how many in the past 6 months? Reason: How many glasses of water/day does your child have? How many glasses of cow s milk, juice, and soda/day? Does your child eat gluten? No Yes Trying to eliminate Does your child eat dairy? No Yes Trying to eliminate Any food/drink allergies or sensitivities? No Yes If yes, please list:

5 FAMILY HISTORY REVIEW Check those involving immediate family identification: M= Mother, F= Father, S= Siblings, G= Grandparents Cancer type, M F S G Depression M F S G Diabetes M F S G Back Problems M F S G Heart Disease M F S G Lung Problems M F S G Seizures M F S G Liver Disease M F S G Scoliosis M F S G Osteoarthritis M F S G High Blood Pressure M F S G Neck Problems M F S G Rheumatoid Arthritis M F S G High Cholesterol M F S G Osteoporosis M F S G Other DO YOU KNOW ABOUT CHIROPRACTIC? Do you know what a subluxation is? Yes No Do any of your friends or relatives see a chiropractor? Yes No If yes, do they use chiropractic for Health maintenance/optimization Health problems Both Are you seeking chiropractic for Health maintenance/optimization Health problems Both What would you like to gain from chiropractic care? Are there other health concerns or anything else you d like us to know about your child? Our goals are to provide a detailed assessment of your child s current health status. To provide to you the resources for a highly engaged and healthy child, whose body is functioning at its absolute peak potential while they grow. Essential to this healthy growth is a nervous system functioning free from interference called subluxations. You ve taken an important step for your child s future through a chiropractic evaluation. CONSENT OF EVALUATION OF A MINOR I,, being the parent or legal guardian of, (Print name of consenting parent/guardian) (Print name of minor) hereby grant permission for my child to receive a chiropractic evaluation including history, scan, and physical examination. Any findings will be communicated before consenting to commencement of treatment, if appropriate. Parent/Guardian Signature Date EMERGENCY CONTACT Name Phone Number Relationship

6 Dr. Stephanie Spiers DC, CACCP 9402 Towne Square Ave. Suite E Cincinnati, OH Consent for Purpose of Treatment, Payment and Healthcare Operation I acknowledge that Bright Futures Family Chiropractic s Notice of Privacy Practices has been provided to me. I understand I have a right to review Bright Futures Family Chiropractic s Notice of Privacy Practices prior to signing this document. Bright Futures Family Chiropractic s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Bright Futures Family Chiropractic. The Notice of Privacy Practices for Bright Futures Family Chiropractic is also provided on request at the main administration desk of this practice. This Notice of Privacy Practices also describes my rights and Bright Futures Family Chiropractic s duties with respect to my protected health information. Bright Futures Family Chiropractic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. Signature of Patient or Personal Representative Date Name of Patient or Personal Representative Description of Personal Representative s Authority Name of Person(s) Authorized to Gain Access to Account Information

7 Dr. Stephanie Spiers DC, CACCP 9402 Towne Square Ave. Suite E Cincinnati, OH TERMS OF ACCEPTANCE When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. ADJUSTMENT: An adjustment is the specific application of force to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. HEALTH: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. VERTEBRAL SUBLUXATION: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter a non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. I have read and fully understand the above statements. All questions regarding the doctor s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. Signature Date APPOINTMENT CANCELATION POLICY Appointments cancelled within 24 hours may be subject to a $25.00 cancellation fee. Signature Date Photo Release Bright Futures is allowed to take pictures of my child. Parent Signature: Bright Futures is allowed to post photos on social media. No names will be used. Parent Signature: