KIDSPACE Adaptive Play and Wellness 469 Buckland Rad, Suite 102 Suth Windsr, CT 06074 CHILDREN AGES 5 thrugh 13 YEARS OLD Intake Questinnaire Tday s : / / Name: f Birth: / / Age: Gender: Street Address: City: State: Zip Cde: Family Status: Parent/Guardian 1: Preferred Phne: ( ) - Occupatin: Email Address: Parent/Guardian 2: Preferred Phne: ( ) - Occupatin: Email Address: With whm and hw shuld we be in tuch regarding yur child s care? Parent/Guardian Text/Call/Email Whm may we thank fr referring yu t KIDSPACE: MEDICAL PROVIDERS and CONSENT TO SHARE RECORDS List the names f yur medical prviders. Check the apprpriate bx t indicate whether r nt yu wuld like us t share recrds. Pediatrician Yes N Dentist Yes N Other Yes N Parent/Guardian 1 Signature: Parent/Guardian 2 Signature:
CURRENT CONCERNS Please list yur cncerns abut yur child in rder f imprtance: 1. 2. 3. 4. What are his/her current symptms: When did they begin? Hw did they begin? Has he/she had any treatment fr these symptms? What are yu gals fr yur child s care at KIDSPACE? Describe yur child in yur wn wrds: PREGNANCY and LABOR Mm s age when baby was brn? Hw many pregnancies? Live births? Any prblems cnceiving? Treatment? Hw was pregnancy verall? During pregnancy was mm n medicatin (ver the cunter/prescribed/recreatinal)? During pregnancy did mm smke r cnsume any alchlic beverages? Was mm in pain during pregnancy? Was mm physically ill? (clds, flu, allergies, German measles, etc.) Was labr chemically induced? Dctr assisted? Apprximately hw lng was labr? Wh was present? C-sectin? Were frceps/vacuum used? Did dctr have hands n the child? What psitin was mm in? Any time in NICU? Why? Hw lng? What was baby s gestatinal age? Length? Weight? Head circumference? Baby s APGARS: 1 min 5 min; Any prblems at birth? Did mm breastfeed? Any prblems? Hw lng? Did mm bttlefeed? What frmula? Any prblems? Did mm see a lactatin cnsultant in hspital? Wh? Did mm see a lactatin cnsultant privately? Wh? 2
MEDICAL HISTORY Please describe any majr illnesses, previus diagnses, hspitalizatins, surgeries, majr accidents/injuries, x-rays, CAT scans, MRIs, EKGs, etc. : Descriptin Please list any knwn allergies (drugs, fd, envirnmental, chemical, etc) and the reactins t them: Please list any and all current medicatins (prescriptin and ver-the cunter) & supplements including (vitamins, herbs, hmepathic remedies): Name f Drug/Supplement Started Dsage/Frequency Prescribed fr: Des yur child have any f the fllwing? Allergies Asthma Bedwetting Bldy Nses Frequent Clds Cnstipatin Cngestin Diarrhea Digestive Prblems Ear Prblems Fatigue Flu Headaches Hyperactivity Irritability Learning Disrders Milk/Lactse Intlerance Meningitis Menses Nervusness Pr psture Rashes Sleeping Disrders Snring/Apnea Other Please describe yur child s habits as gd, fair r pr: Bwel Eating Listening Md Sleeping Physical Strength 3
Has yur child had any f the fllwing illnesses? Measles German Measles Mumps Pneumnia Scarlet Fever Chicken Px Cancer Rheumatic Fever Urinary Tract Infectin RSV Rtavirus Strep Thrat HIV/AIDS Tuberculsis Other Illnesses Has yur child had any extensive dental wrk, extractins r rthdnture? Des yur child have difficulty with fd textures, chewing, r swallwing slids r liquids? DEVELOPMENTAL INFORMATION Please indicate which imprtant milestnes yur child has attained. If he/she was late please indicate. Sitting up Crawling Walking Talking Skipping Standing n ne ft Catching a ball Scializing Is there anything yu wuld like t tell us abut yur child s develpment thus far? SCHOOL AND SOCIAL HISTORY Is yur child hme-schled r enrlled in a traditinal public, private, r special schl? Des yur child experience stress frm schl wrk lad? Academic perfrmance? Peers? Athletic perfrmance Other interests? Des yur child have sensry sensitivities? Difficulties with Crdinatin? 4
IMMUNIZATION RECORD Please recrd the date f each immunizatin given t yur child. Vaccine Given (m/d/yy) Vaccine Hepatitis B Hepatitis A Diptheria, Tetanus, Pertussis Meningcccal Given (m/d/yy) Human papillmavirus Zster (shingles) bsters Influenza (yearly) Haemphilus influenzae type b Pneumcccal Other Pli Rtavirus Measles, Mumps, & Rubella Varicella (chickenpx) Is yur child up t date n all immunizatins? Yes N Please list any adverse reactins t immunizatins. Please be specific. Were these reactins reprted t VAERS? Yes N 5
FAMILY MEDICAL HISTORY Please specify maternal vs paternal grandparents. Mther Father Brthers Check if applicable Cancer Diabetes Heart Disease High Bld Pressure Strke Epilepsy Mental Illness Asthma Kidney Disease Autimmune Disease Other 6 Sisters Maternal/Paternal Grandparents
CONSENT FOR TREATMENT OF A MINOR We, the parents r guardians, cnsent t the treatment/prcedure rendered t ur child r ward under general and specific instructins f my child's health care prvider including but nt limited t chirpractic, CraniSacral therapy, massage, sensry prcessing, r recreatinal therapy, as well as nutritinal, hmepathic and herbal therapies and whle health cunseling. We have had the mechanisms and risks f chirpractic adjustments based n pediatric anatmy and physilgy explained t ur satisfactin and authrize said treatment n the abve-named child understanding the risks and incidence f deleterius effect. We recgnize that even the gentlest therapies may ptentially have cmplicatins in very yung children, r in thse n multiple medicatins. Hence, the infrmatin we have prvided ur health care prviders is cmplete and inclusive f all health cncerns and medicatins, including ver-the-cunter medicatins, supplements, and herbs ur child may be taking. With this knwledge, we vluntarily cnsent t the prpsed prcedures. We acknwledge that n guarantees f cure r imprvement f cnditin have been made. We understand that we are free t withdraw cnsent and t discntinue treatment at any time. We attest that we are the legal parent(s)/guardian(s) and are designated and authrized t make healthcare decisins and cnsent t healthcare fr this child. Our practice is cllabrative in nature. We ften cnsult with each ther and c-manage in rder t best serve ur patients. Yu are respnsible fr infrming ur prviders f any relevant infrmatin r changes that affect yur child s health. Shuld privileged infrmatin be shared via text message r email, yur prvider will make every effrt t maintain privacy but text messaging and emailing are nt encrypted r HIPAA-apprved means f cmmunicatin. Parent/Guardian Signature 1 Parent/Guardian Signature 2 CONSENT TO PHOTOGRAPH Phtgraphs f yur child help us see changes and help us teach ther health care prviders abut caring fr children with similar prblems. Due t HIPAA regulatins, we will ask permissin frm yu t phtgraph yur child and wuld like yu t check beside each item that yu cnsent t use yur child s pht fr: Recrding prgress in the child s chart: Yes N Fr use in a prfessinal presentatin: Yes N Fr use in a prfessinal publicatin: Yes N Parent/Guardian Initials Parent/Guardian Initials Parent/Guardian Initials 7
PARENT RESPONSIBILITIES We agree t be financially respnsible fr all charges incurred at this ffice. We will make payment as required at the time f service. Shuld cllectin effrts be necessary t cllect mney wed, a 15% interest charge will be added t the balance due. We are liable fr any cst incurred by the ffice in cllectin effrts. CANCELLATION POLICY If yu are unable t make yur appintment, please prvide at least 24-hur ntice f cancellatin. A cancellatin fee f $50 will apply fr appintments cancelled with less than 24-hur ntice. Signature Our ffice requires a credit card t be kept n file fr any charges incurred. ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES This dcument is t be signed by persns legally respnsible fr the patient s medical decisins relative t the treatment situatin. We,, hereby acknwledge that we have been prvided with a cpy f the Ntice f Privacy Practices that describes hw medical infrmatin abut ur child/guardian may be used and disclsed, and hw we can access that infrmatin. We understand that if we have questins r cmplaints, I may cntact: Faraneh Carnegie-Hargreaves, DC, Karen Peck CTRS, CST, QST; r Sharn A. Vallne, DC, FICCP at 860.432.9923. We als understand that we are entitled t receive updates upn request if this ffice amends r changes its Ntice f Privacy Prcedures in a material way. Parent/Guardian 1 Signature Parent/Guardian 2 Signature This sectin is t be cmpleted by ur ffice, if unable t btain written acknwledgement frm patient. I made a gd faith effrt t btain written acknwledgement f receipt f the Ntice f Privacy Practices frm the abvenamed patient, but was unable because: [ ] Patient declined t sign this written acknwledgement. [ ] Other (specify): Name and title f emplyee 8