Patient Introduction Child (to age 12)
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- Rudolf Hubbard
- 6 years ago
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1 #204, 1740 Gordon Drive Kelowna, BC V1Y 3H Patient Introduction Child (to age 12) Personal History: Your Name: First (Nick-name) Last Your Mom: Your Dad: Your Mailing Address (including postal code please): Telephone: Home: Mom s cell: Dad s cell: Birth Date: Day: Month: Year: Previous Chiropractor: Last visit to this Chiropractor: City: Reason for leaving: Present MD: City: Referred to our Centre by:
2 #204, 1740 Gordon Drive Kelowna, BC V1Y 3H Initial Child & Adolescent Questionnaire (to age 12) Patient s Name: Your Mom: Gender: Your Dad: Mainly for Moms: 1. Tell us about your pregnancy; Did you carry to full term? Describe any complications and when they occurred: 2. Tell us about your delivery and birth of this child: Did you use a midwife? Hospital? Obstetrician? Did you have a C-Section? Vacuum Extraction? Did you have an Epidural? What was the baby=s APGAR Score? Were forceps used? Were you induced? Was it a difficult birth? at 5 minutes? 3. Tell us more: Did you breastfeed? How long? What formula after? Did you consume alcohol during your pregnancy? How much? Did you smoke? How much? How long? Did you take any medication during your pregnancy? For what? Any exposures to ultrasound? What type?, How many?
3 4. As a baby/toddler, (birth to 4 years), did any of the following occur? Fall from a change table Frequent crying spells Tumble down stairs Frequent fevers Fall out of crib Frequent bouts of diarrhea Involved in car accident Constipation Fall off playground equipment Sleeping problems Play in AJolly Jumper@ Frequent colds Frequent ear infections Colic Tonsilitis Did not gain weight Reaction to vaccination Other Please explain the above: 5. As a young child, (5-12 years), did any of the following occur? Fall from a tree Bed wetting Fall of a bicycle Hyperactivity/Autism Fall of playground equipment Learning difficulties Sports accident Asthma Car accident Allergies Stomach pains Leg/knee pains Scoliosis Other Please explain the above: 6. Did your child receive any vaccination(s)? If so, which ones: _ Any reactions to any of these? 7. As a child or adolescent, has your child experienced any of the following: Headaches Numbness in arms/hands Foot/ankle/knee pains Dizziness Arm/wrist pains Tingling in arms/legs Ringing in ears Sleeping problems Neck/back pains Asthma Allergies Shoulder pains Hyperactivity Stomach problems AGrowing Pains@ Fatigue Weight gain/loss Other Please explain any of the above: OVER
4 8. Which of the problems you have checked off is the worst? Is this problem: Constant, Intermittent, Occasional, Cyclic 9. How long has it persisted? 10. When it is at its worst, how does it make your child feel? 11. What have you done about it that has NOT worked? 12. What makes it worse? 13. What effect does this problem have of your child=s body functions? On his/her participation in daily activities? 14. Describe any hospital stays: 15. Approximately how many times have antibiotics been prescribed and for what conditions? 16. List any medications your child is currently taking: 17. To summarize, what is your purpose for this appointment? 18. Is there anything else you feel we should know? Signature of parent or guardian: Date: _ ***
5 FAMILY HEALTH HISTORY Patient Name: Date: Please review the diseases and conditions listed below and indicate those that are current health problems of a family member by the designation C under his or her column. The designation P should be used to indicate a past problem. Leave blank those spaces that do not apply. Condition Self Father Mother Spouse Children Age Age Age ADHD Allergies Arthritis Asthma Autism Back Trouble Bed Wetting Bursitis Cancer Chest Pain Colic Constipation Crohn Disease Depression Diabetes Diarrhea Disc Problems Down Syndrome Ear Infection Emotion Issues Emphysema Epilepsy Headaches Migraines Heartburn Heart Trouble High Blood Press IBS Indigestion Infertility Insomnia Kidney Trouble Neck Pain Neuritis Nervousness Pinched Nerve Scoliosis Sinus Trouble Other Additional Comments:
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ADIO CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
PEDIATRIC HISTORY FORM
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: EMAIL: HOW DID YOU FIRST HEAR OF CORRECTIVE
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy Patient Number: Date of First Visit: Last Name: First Name: MI: Address: City: State: Zip Code: Email address: Phone: H
New Patient Information
(Please Print) New Patient Information Name Address City/State/Zip Cell: Home: email: Social Security # Birthdate Age Male Female Occupation Employed by Wk ph. # Address City/State/Zip Number of Children
Consent to Treat a Minor
1. Fill out the application for treatment sheets, two of them, and sign both of them accordingly. 2. If the appointment is for a minor, please read the Consent to Treat a Minor carefully and sign accordingly.
ADULT CHIROPRACTIC INTAKE FORM
ADULT CHIROPRACTIC INTAKE FORM Welcome to our office! It is well known that families who maintain strong, healthy, wellaligned spines have greatly improved health. People whose spines are not healthy and
Cascadia Chiropractic Centre
Name: Address: Dr. Simpson Leung Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: City: Province: Postal Code: Phone: Cell: Work Phone: Date of Birth: E-mail Address: Care Card