PEDIATRIC HISTORY FORM
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- Lesley Nash
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1 PEDIATRIC HISTORY FORM CHILD S NAME: NICKNAME: SSN: BIRTHDAY: AGE: MALE FEMALE NAME OF PARENTS/GUARDIANS: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL/WORK PHONE: HOW DID YOU FIRST HEAR OF CORRECTIVE CHIROPRACTIC? PARENT IS A PATIENT TV NEWSPAPER BILLBOARD FRIEND OTHER: WHO CAN WE THANK FOR REFERRING YOU TO US: PURPOSE FOR CONTACTING US? OTHER DOCTORS SEEN FOR THIS CONDITION? YES NO IF YES, PLEASE LIST DOCTORS AND TREATMENTS: HEALTH HISTORY: CHECK ANY OF THE FOLLOWING CONDITIONS YOUR CHILD HAS SUFFERED FROM DURING THE LAST 6 MONTHS: EAR INFECTIONS ASTHMA/ALLERGIES COLIC SCOLIOSIS DIGESTIVE PROBLEMS BED WETTING SEIZURES ADHD CAR ACCIDENT CHRONIC COLDS RECURRING FEVERS HEADACHES GROWING PAINS NECK PAIN BACK PAIN SLEEPLESSNESS ECZEMA / SKIN PROBLEMS OTHER: HAS YOUR CHILD EVER BEEN HOSPITALIZED? YES NO IF YES, WHY? HAS YOUR CHILD HAD ANY SIGNIFICANT INJURIES? IS YOUR CHILD ON ANY MEDICATIONS? HAS YOUR CHILD TAKEN ANY ANTIBIOTICS? NO YES; IF YES, HOW MANY DOSES IN THE LAST 6 MO? TOTAL DURING HIS/HER LIFETIME: HAS YOUR CHILD BEEN VACCINATED? NO YES; WHEN: ANY CHILDHOOD DISEASES? CHICKEN POX RUBELLA WHOOPING COUGH MUMPS RSV OTHER: MEASLES PERTUSSES NAME OF PEDIATRICIAN: PRENATAL HISTORY: MOM S HEALTH DURING PREGNANCY: COMPLICATIONS DURING PREGNANCY: NO YES ; PLEASE LIST: MEDICATIONS DURING DELIVERY: INDUCTION YES NO EPIDURAL YES NO OTHER: BIRTH INTERVENTION: FORCEPS VACUUM EXTRACTION CAESARIAN EMERGENCY / PLANNED? COMPLICATIONS DURING DELIVERY: NO YES ; PLEASE LIST:
2 DELIVERY: < 36 WEEKS WEEKS > 42 WEEKS BIRTH WEIGHT: LENGTH FEEDING HISTORY: BREAST FED: YES NO ; HOW LONG? FORMULA FED: YES NO ; HOW LONG? INTRODUCED TO SOLIDS AT: MONTHS; COW S MILK AT MONTHS FOOD / JUICE ALLERGIES OR INTOLERANCES NO YES; PLEASE LIST: DAILY ACTIVITES/SPORTS IS YOUR CHILD INVOLVED IN ANY HIGH IMPACT OR CONTACT TYPE SPORTS? (I.E. SOCCER, FOOTBALL, GYMNASTICS, BASEBALL, CHEERLEADING, MARTIAL ARTS, ETC) PLEASE LIST ANY INJURIES AS A RESULT OF THEIR ACTIVITIES: REGARDING SYMPTOMS: IS IT RELATED TO AN AUTOMOBILE ACCIDENT? NO YES WHEN DID THE SYMPTOMS FIRST START? HOW FREQUENT IS THE PAIN? HOW DID THIS HAPPEN? DESCRIBE THE PAIN: WHAT MAKES IT WORSE? WHAT MAKES IT BETTER? DOES IT RADIATE TO ANY OTHER PARTS OF YOUR BODY? HAS THIS CHANGED ACTIVITIES AT HOME? Please mark the areas of all of your complaints on the diagrams to the right. N = numbness T = tingling P = pain W = weakness PARENT/GUARDIAN SIGNATURE: DATE:
3 TERMS OF ACCEPTANCE When a person seeks chiropractic and rehabilitation health care, and is accepted for such care, it is essential for both parties to be working towards the same objective. As a chiropractic and rehabilitation facility we have one main objective: to detect and correct/reduce the vertebral subluxation complex. It is important that each person understand both the objective and the method that will be used to attain this objective, thus preventing any confusion or disappointment. 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. Adjustment: A specific application of force to facilitate the body s correction of vertebral subluxation. We do not offer to treat symptoms, but rather to determine if a patient has subluxations. If present, we will recommend a course of treatment including adjustments and rehabilitation procedures in an effort to achieve maximum correction of this dysfunction. PROCEDURES No Charge Consultation- This is a brief meeting between you and the doctor to determine if you may benefit from the care we provide. There is no financial obligation in connection with this service. Exam- After your consultation, if the doctor believes you will likely benefit from the care we provide, a thorough orthopedic, neurologic, and chiropractic examination will be recommended. X-Rays- Based upon the exam findings, the doctor may recommend selected x-rays be taken. Report of Findings- Included in the cost of the examination is a report of findings. This is where the doctor presents his findings regarding your health to you. The doctor will explain what he feels to be the best and fastest approach to improved health for you, if any. Treatments- Include spinal and extra spinal adjustments, intersegmental traction, interferential therapy, curve restoration traction, core muscle training, rehabilitation, posture correction exercises, decompression, custom orthotics, nutritional recommendations and supplements. PAYMENT POLICY Payment is expected at the time of service unless some other arrangement has been made between you and the doctor prior to treatment. Health/Automobile Insurance o Your insurance coverage is a contract between you and your insurance company. We will gladly help you verify what your particular coverage is; however, we cannot take responsibility for what your insurance does or does not cover. Ultimately, all services rendered to you are charged directly to you and you are responsible for payment. o In-Network Policies: We will file your insurance claim for you and do everything we can do to ensure you receive proper reimbursement. Co-pays will be paid by patient, reimbursement checks will be payable to us. o Out-of-Network Policies: We will give you receipts to file with your insurance company. Patient will pay cash prices up front. Insurance company will reimburse the patient. o If your policy has a deductible feature, it is due at the time of service. o In accordance with Medicare Guidelines, Maintenance Care is not a covered benefit and therefore will not be billed to your insurance company. o We will do our very best to answer any questions you may have in regard to your insurance. There will be a $25 charge on any returned checks (plus the original amount of the check) By my signature below, I acknowledge that I have read and agree to the above TERMS OF ACCEPTANCE. PARENT/GUARDIAN SIGNATURE DATE
4 INFORMED CONSENT I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physiotherapy, examination, traction, and, if necessary, diagnostic x-rays, on me by the doctor of chiropractic and/or by other office or clinic personnel. POSSIBLE RISKS I understand and am informed that, as in all health care, in the practice of chiropractic, there are some risks to treatment. These include muscle strain, ligament sprain, fracture, disc injury, dislocation, paralysis, stroke, stiffness and soreness. The ancillary procedures could produce skin irritations, burns, or minor complications. PROBABILITY OF RISKS OCCURING The risks of complications due to chiropractic treatment have been described as rare, about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered rare. OTHER TREATMENT OPTIONS THAT COULD BE CONSIDERED Over-the-counter analgesics. Temporarily relieves pain but does not address the cause of the symptoms. Masking the pain means you may not feel additional damage. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases. Medical care, typically anti-inflammatory drugs, injections, and analgesics. Temporarily relieve pain but do not address the cause of the symptoms. Masking the pain means you may not feel additional damage. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases. Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases. Surgery in conjunction with medical care adds the risk of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases. RISKS OF REMAINING UNTREATED Can further reduce ranges of motion, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and delay of treatment allows formation of adhesions, scar tissue and other degenerative changes including arthritis. These changes make future rehabilitation more difficult. CONSENT I acknowledge I have discussed, or have had the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general and my treatment in particular (including spinal adjustment) as well as the contents of this Informed Consent. I consent to the chiropractic treatments offered or recommended to me by my chiropractor. I intend this consent to apply to all my present and future chiropractic care. ADDITIONAL PRIVACY PRACTICES We may call you by name in the reception area when the doctor is ready to see you. A postcard may be mailed to you at the address provided by you. When telephoning your home we may leave a message with whomever answers or on your answering machine. We may include a photo of you on our referral wall. PARENT/GUARDIAN SIGNATURE DATE
5 Corrective Chiropractic and Wellness Acknowledgement of Receipt of Notice of Privacy Practices This form will be retained in your medical record. NOTICE TO PATIENT We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. Patient Name: Date of Birth: I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices on the date below on behalf of Corrective Chiropractic and Wellness. I understand that the Notice describes the uses and disclosures of my protected health information by Corrective Chiropractic and Wellness and informs me of my rights with respect to my protected health information. Patient s Signature or that of Legal Representative Printed Name of Patient or that of Legal Representative Today s Date If Legal Representative, Indicate Relationship FOR OFFICE USE ONLY We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because: The patient refused to sign. Due to an emergency situation it was not possible to obtain an acknowledgement Communications barriers prohibited obtaining the acknowledgement Other (please specify): Employee Name Today s Date
Last Name First Name M.I Nickname Address City State Zip_. Date of Birth Age Gender: M F Marital Status: S M W D INJURY INFORMATION
PATIENT REGISTRATION Date: Last Name First Name M.I Nickname Address City State Zip_ Mobile Phone Home Phone Work Phone E-Mail SSN Date of Birth Age Gender: M F Marital Status: S M W D Employer Name Occupation_
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Welcome To Corporate Chiropractic Works!
Welcome To Corporate Chiropractic Works! When a person seeks the services of a chiropractor, it is important to fully understand the purpose and intent of that particular chiropractor and the chiropractic
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation:
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
PEDIATRIC PATIENT QUESTIONNAIRE
2Dr. Stephanie Spiers DC, CACCP 9402 Towne Square Ave. Suite E Cincinnati, OH 45242 513-792-9111 www.brightfuturesfamilychiro.com PEDIATRIC PATIENT QUESTIONNAIRE Child s Name: Nickname: Date: Parent(s)
Dr. Brett Whitekettle
Dr. Brett Whitekettle For Office Use Only: Patient ID #: 200 Cape Fear Circle Suite 2 Sneads Ferry, NC 28460 T: (910) 327-0022 F: (910) 327-0337 office@whitekettlechiropractic.com Patient Information Phone
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
NEW PATIENT PAPERWORK
NEW PATIENT PAPERWORK Welcome! Please fill out the necessary paperwork provided. It is our pleasure to serve you and your family. How did you find out about us? If It was a friend or doctor, please list
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Address
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Email Address Do you have Medicaid? Y / N (present your card to
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
CHIROCENTER. Home Address: City: State: Zip: I would like to receive notifications Please do not send notifications
CHIROCENTER PATIENT ADMITTANCE Name: (First) (Middle Int). (Last) Today s : Home City: State: Zip: Telephone: Work: Cell: of Birth: Sex: M or F Social Security#: (Month) (Day) (Year) Circle if you are:
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Chiropractic Intake Form Name Date Address City State Date of Birth Age Phone Email Address Employer Emergency Contact Phone
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phone: Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single/Married/Divorced/Widowed Spouse s Name Number of Children
Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
A Natural Path toward health
Pediatric Intake Form (Newborn - 12 years) Welcome! It is my goal to provide your child with the best possible health care. In order to serve you optimally, please answer the following questions about
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
LIST YOUR HEALTH CONCERNS BELOW
T 1 2 3 ROOTS CHIROPRACTIC HEALTH PROFILE In Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Work Email Address Date of Birth / / Occupation Employer's Name Single / Married / Divorced
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
Describe the pain and it s location:
WELCOME TO ZIVKOVIC CHIROPRACTIC CENTER DATE: Please print clearly and fill in completely. ABOUT YOU: Patient Name:_ What do you prefer to be called:_ SS# Street Address City State Zip Date of Birth: Age: