Chiropractic New Patient Form- Baby to 4 Years

Yost Family Chiropractic New Patient Forms

Please fill in the form below before your appointment.
Patient Information
Name *

First Name Middle Name Last Name
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth *

Month Day Year
Sex *
Parent's Name *
Phone Number *

Area Code Phone Number
Parent's Name
Phone Number

Area Code Phone Number
Primary e-mail *
Referred By:
Family/Friend/Doctor's Name
Primary Care Physician & Location
Labor and Delivery
Third Trimester Presentation *

Vertex Breech Transverse Face/Brow
Type of Birth

Normal Vaginal Forceps Cesarean Suction Cap/Vaccuum
Location of Birth

Home Birthing Center Hospital
How long were you in labor?
How long did you push for?
Please list any problems during pregnancy and/or labor
Were any medications administered at birth?
Was your baby premature?

No Yes
At time of birth was the child jaundice? (yellow)

Yes No
At time of birth was the child cyanosis? (blue)

Yes No
Birth Weight
Birth Height
Time of Birth (AM/PM)
Current Weight
Did the mother use any cigarettes, alcohol, or drugs during pregnancy?

Yes No
Any congenital anomalies or defects?

Yes No
If yes, please explain:
Past & Current Condition
Does your child have or have had any of the below (check all that apply)

Neck Pain Headaches Torticollis Midback pain Scoliosis Lower Back Pain Fall/Injury Hip Dysplasia Shoulder Pain Knee pain
Please check each of the following the your child currently has or has had in the past *

Measles/Mumps Cancer Constipation Chicken Pox Colic Eczema/Skin Problems Allergies Ear Infection Pneumonia Frequent Colds/Sore Throat Headaches Asthma/Wheezing Diarrhea Dizziness Seizures Orthopedic Problems Neck problems Scoliosis Walking Trouble Broken bones Digestive Issues Reflux Hypertension Bed Wetting Behavior Problems ADD/ADHA Growing Pains Sleep Problems
Please list current medications or supplements your child takes. *
How many doses of antibiotics has your children taken in his/her history?
Has your child ever suffered from any of the following spinal traumas?

Fall from crib Fall from highchair Fall from changing table Fall from bed or couch Fall from play equipment such as slide, monkey bars, ect. Fall off bicycle, skates, scooter, or skateboard Fall down stairs Any large object falling on them
Has your child ever had to receive emergency treatment or be hospitalized?

Yes No
If yes, please explain.
When was your last visit to the pediatrician and what was the purpose of the visit?
At what age did your child:
Respond to sound
Follow an object with their eyes
Hold head up
Sit alone
Crawl
Stand
Walk alone
The following questions are designed to allow the doctor to provide a detailed evaluation of your child. If a question is not relavent to your child, please answer "N/A"
How many hours does your baby sleep between feeds during the day and night?
Does your child go to sleep easily?

Yes Sometimes No
Does your child have a preferred sleeping position? If yes, what is it?
Does your child cry if you change this sleeping position?

Yes Sometimes No N/A
Does your child have any difficulties feeding?

Yes Sometimes No
Is baby breast fed or formula fed?

Breast Formula Both
If you breast fed but don't anymore, how long did you breast feed?
If you breast fed, did baby favor one side over the other?
If you formula fed, what brand did you use?
Does your baby frequently spit up after feeding?

Yes Sometimes No
Does your child eat solid food? If so, what types of food do they eat? Do they have a favorite food?
Does your child have any known food allergies?

Yes No
If yes, please list.
Does your baby cry a lot?

Yes Sometimes No
Does your baby pass a lot of gas?

Yes Sometimes No
Does your baby frequently arch their head and neck backwards?

Yes Sometimes No
Does your baby cry or become irritable during diaper changes?

Yes Sometimes No
Does your baby have a preferred head position?

Yes No
Do you have any other concerns you want to discuss?
Have you ever taken your child to a chiropractor before?

Yes No
If yes, please explain. When was it, with whom, and what were your results?
Informed Consent
I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge.

I consent to the collection and use of the above information to this office. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I consent the office staff and doctors to use my contact information for the purpose of appointment reminders and any necessary annoucements.

I understand that like any and all medication procedures, there are risks. These include but are not limited to, fractures, disc injurieres, strokes, dislocations, sprains. I do not expect the doctor to be able to anticipate all risks and complications and I wish to rely on the doctor to exercise judgememt during the course of the procedure that is in my best interest. Acupuncture may present it's own side effects such as some pain following treatment in the insertion location, minor bleeding from insertion point, minor bruising, infection, dizziness or faint feeling,

I understand that there is no guarantee of results. It is understood that every patient is unique and can be affected by treatment in different ways.

I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for payment at time of service. I will secure my account with a credit card on file. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment with the secured credit card on my account.

The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation as deemed necessary by the doctor.
Please list the full names of any parties that you grant permission to receive your personal health information. Ex: parents, spouse, significant other, ect.
This office conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at the front desk. If you wish for the policy to be explained, please ask a front desk staff. Please check to indicate you have been made aware of its availability: *

Yes No
Signature *

Clear
Yost Family Chiropractic strives to ensure each patient reaches their maximum potential. Our missed appointment policy helps to ensure this. Faliure to come to a scheduled appointment with no communication to the office will result in a missed appointment fee of $30 and will be used with the credit card on file. The staff will always make an attempt to contact you upon being 15 minutes late and the fee will not be charged until the end of the business day. If the patient reschedules before the end of the day, no fee will be assessed. Please sign below indicating you understand the policy.

**Extrenuating circumstances will alwasy be considered.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Yost Family Chiropractic New Patient Forms

Patient Information

Labor and Delivery

Past & Current Condition

Informed Consent