Welcome to our office!

Transcription

1 Welcome to our office! In just a short time from now, I ll get to meet you and discover how we may be able to help you with safe and natural NUCCA chiropractic care Until then, by completing the paperwork that follows, I ll be able to learn what has brought you to our office and how I might be able to help you Since I m going to ask you some personal information, it s only fair that I share some information about myself! I was introduced to chiropractic in 1994 after I was in a serious snowboarding accident I had tried traditional approaches to resolve the difficulty I had with my knee and walking but it wasn t until I visited a chiropractor that I got relief That inspired me to change my career path and become a chiropractor Just as I was making this life changing decision, I met the most wonderful woman in the world, Marie, and we got married in 1999 We started our family three years later and we ve been blessed with four active children; two outrageously smart and busy boys, Caden and Kaleb who keep us moving at all times, and two sweet princesses, Makaela and Kiara, who both have contagious smiles that welcome everyone they meet We want the best for them and cherish them more than anything in the world In the summer, you almost always will find me mountain biking somewhere In the winter, I m usually on my snowboard And on the off days, I love to hang out at the gym with my wife My family loves to join me as well and we have a lot of fun being active together It s one of my greatest joys! I love to be active and thanks to a healthy spine, I can enjoy the things I love to do! With all of the various physical, chemical, and psychological stressors present these days, my family and I see a chiropractor on a regular basis It keeps our nervous systems interference-free, our immune systems PRECISIONSPINALCARE life improved strong, and helps us do our best in all aspects of our lives I guess you could say it helps us live a life improved I want you and your family to experience the same Thank you for your trust and confidence I look forward to personally meeting you and seeing how we can help you achieve your individual health goals Yours in health, Dr Ryan Dr Ryan Brown p e d i a t r i c a d m i s s i o n f o r m! 1 of 2! # Sunpark Drive SE Calgary, AB T2X 3V info@precisionspinalcareca wwwprecisionspinalcareca TELEPHONE FACSIMILE WEBSITE

2 # Sunpark Drive SE Calgary, AB T2X 3V4 t Clinic Director ID# P Today s Date: M M / D D / Y E A R recision Spinal Care seeks to provide the highest quality chiropractic care available in an inviting and healing atmosphere, instilling the concept of true health and wellness We are committed to the health and wellness of your entire family Our practice members receive the highest quality of chiropractic care, following the Upper Cervical System approach of NUCCA protocol and procedures We hold ourselves to an exceptional level of care to those we take care of We provide a warm, nurturing environment for our members to begin their healing process, and to continue their journey of lifetime wellness care to experience true health through upper cervical chiropractic If we do not sincerely believe you will respond satisfactorily, we will not accept your case but will work to refer you to the appropriate health care provider GENERALINFORMATION Name Sex M F Address City Province Postal Code Whom may we thank for referring your child to us? Home Phone _ Date of Birth (mm-dd-yy) Age Parent/Guardian Phone Present Weight Present Height/Length Parent/Guardian Business Phone Parent/Guardian Name(s) Pediatrician/Doctor Date of Last Visit Reason Names of Siblings 1 Age 2 Age Parent/Guardian Address Would you like us to send reminders to you at the address above before your appointments? yes no If yes, how many days in advance? 1 2 Emergency Contact Name Emergency Contact Phone 3 Age 4 Age p e d i a t r i c a d m i s s i o n f o r m! 2 of 2!

3 L ife is a miracle and so are you You deserve to be healthy The human body is designed to be healthy When you were created, you were given all the blueprints, intelligence, tools, and systems to live an active and healthy life Unfortunately, throughout your life, your health can be interfered with through accidents and events that cause a disruption to your health expression With your commitment to improve your health and adopt chiropractic into your lifestyle, we will work to remove these interferences to your natural health expression so that you can live the quality of life you want and deserve CONDITIONPROFILE What is the primary reason for your child consulting our office? The child has no complaints, he/she is here for a wellness check-up 1 For how long? What are your expectations for your child receiving care in this clinic? What phrase most accurately reflects the reason for seeking care for your child? wellness prevention feel good symptom relief Have your child had similar problems in the past? no yes When? Does anything initiate the condition? Does anything aggravate the condition? Does anything relieve the condition? Is it worse in the morning or the night? morning night no change Is it constant? yes no Is this condition getting progressively worse? yes no it comes and goes Onset of problem was: sudden gradual associate with an event Explain Duration of problem: minutes hours days months years Other health concerns _ Has your child ever been to a chiropractor before? no yes When was the last visit? Reason for visit Doctor s name Please list other doctors that your child has consulted for these conditions Doctor s name Diagnosis Doctor s name Diagnosis Please list any prescription medications your child is currently taking for? for? for? for? Please list any antibiotics your child is currently taking or has previously taken never had antibiotics none at this time for? for? for? Please list any vaccinations your child has had and at what age Were there any negative no yes Explain reactions? Reason for vaccinations Please list any surgeries, hospitalizations, and/or broken bones your child has had for? for? for? for? Has your child ever been in an auto accident? never past year past 5 years over 5 years PRECISIONSPINALCARE p e d i a t r i c a d m i s s i o n f o r m! 1 of 3!

4 General History HEALTHPROFILE Childhood Illnesses Yes No? Yes No? Age Ear infections Chicken pox Asthma/allergies Rubella Colic Croup Scoliosis Digestive Fifth disease Thrush problems Bed wetting Measles ADHD Mumps Chronic colds Whooping cough Recurring fevers Scarlet fever Temper Other tantrums Headaches Seizures Birth History Pregnancy duration weeks Location of birth hospital birthing centre home midwife Assisted birth? no yes If yes - c-section induced labor forceps vacuum other Were medications given to mother during birth? no yes If yes, Duration of birth Complications at birth? what? no _ yes Explain Ultrasounds during yes no Was delivery normal? yes no Explain pregnancy? APGAR score don t know Birth weight Birth length Growth & Development Was the infant alert and responsive within 12 hours of yes no Explain delivery? At what age was your child able respond to sounds follow an object hold head up sit up alone to: crawl stand walk vocalize Do your child s sleeping patterns seem normal to you? yes no Explain STRESSPROFILE Since problems that Chiropractors concern themselves with can be related to many types of stresses, the following is very important to us: Chemical Stresses Was (is) the child breast-fed? no yes How long? Was formula no yes At what age? Type of formula used introduced? Introduced to cow s milk? no yes At what age? Introduced solids? no yes At what age? Food/Juice intolerance? no yes Type During the pregnancy, did the yes no Drink alcohol? yes no mother Did the mother have any illnesses during Smoke? the pregnancy? yes no Any pets at home? yes no Any smokers at home? yes no Psychosocial Stresses Any difficulties with yes no Any problems with bonding? yes no lactation? Any behavioral problems? yes no Onset Do you feel that your child s social and emotional development is normal for their age? yes no Explain Any of the following? night terrors? sleep walking? difficulty sleeping? other? Traumatic Stresses Any trauma during pregnancy (fall, accidents)? no yes Explain Was there any evidence of birth trauma to the child? Check all that apply: bruising stuck in birth canal odd shaped head respiratory depression fast birth excessively long birth cord around neck other Any falls from - couches beds change tables other Any trauma with - bruising cuts stitches fractures other _ Sports played and age started Is a school backpack used? no yes weight - heavy light don t know PRECISIONSPINALCARE p e d i a t r i c a d m i s s i o n f o r m! 2 of 3!

5 INFORMED CONSENT Our sole objective is to locate, analyze, and correct interference to the nervous system There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic In particular you should note: a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures; b) There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stoke Recent studies suggest that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke In essence, there is a stroke already in progress However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death The possibility of such injuries occurring in association with upper cervical adjustment is extremely remote; c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this Consent I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal adjustments I intend this consent to apply to all my present and future chiropractic care TO BE COMPLETED BY THE PRACTICE MEMBER/PARENT: Practice Member Signature X Date M M / D D / Y E A R Witness Signature X PREGNANCY RELEASE: This is to certify that to the best of my knowledge I am not pregnant and that I give permission to the doctors and/or licensed staff at PRECISIONSPINALCARE to perform an x-ray evaluation (if needed) I understand that x-rays pose a serious potential risk to the health and welfare of a developing child Signature X PRECISIONSPINALCARE life improved PRECISIONSPINALCARE p e d i a t r i c a d m i s s i o n f o r m! 3 of 3!

6 Directions to Our Office Sunpark Drive SE South on Deerfoot Trail Take the BOW BOTTOM TR SOUTH/ANDERSON RD WEST exit (exit 243) Take the ANDERSON RD WEST ramp Merge onto MACLEOD TRAIL SOUTH via the ramp on the LEFT Turn LEFT onto SUN VALLEY BLVD Take 2nd RIGHT onto SUNPARK DRIVE (right after Petro Canada gas station) Continue 1 block Building is on the RIGHT hand side Entrance is in the back of the building Office is on the main floor to the right as you enter the building South on Macleod Trail Turn LEFT onto SUN VALLEY BLVD Take 2nd RIGHT onto SUNPARK DRIVE (right after Petro Canada gas station) Continue 1 block Building is on the RIGHT hand side Entrance is in the back of the building Office is on the main floor to the right as you enter the building North on Highway #2 Turn RIGHT onto SUN VALLEY BLVD Take 2nd RIGHT onto SUNPARK DRIVE (right after Petro Canada gas station) Continue 1 block Building is on the RIGHT hand side Entrance is in the back of the building Office is on the main floor to the right as you enter the building PRECISIONSPINALCARE life improved