Pediatric Health History

Pediatric Health History
TERMS OF ACCEPTANCE

CHIROPRACTIC HAS ONLY ONE GOAL AND THAT IS TO REMOVE NERVE INTERFERENCE CAUSED BY A MISALIGNMENT OF SPINAL BONES. IT IS IMPORTNAT THAT YOU UNDERSTAND THAT DIAGNOSING CONDITIONS, TREATMENT OF CONDITIONS, AND REMOVING PAIN IS NOT THE GOAL OF THIS OFFICE. LOCATING, ASSESSING, AND CORRECTING VERTEBRAL SUBLUXATION IS THE ONLY GOAL OF THIS OFFICE. ALTHOUGH THIS OFFICE MAY RELIEVE YOU OF SOME PAIN, MAINTAINING YOUR HEALTH AND FAMILY'S HEALTH THROUGH REGULAR SPINAL CHECKUPS AND SPINAL ADJUSTMENTS IS OUR PRIMARY GOAL.

"I understand that I will pay a total value of $100 (individual) or $150 (family of 2 or more members) for the initial visit. The initial visit consists of history taking, neurological chiropractic examination, reading of the radiology films, determing a uniquely designed care plan, goal setting, and the report of finding(s)."
Cancellation Policy:

A $25 charge will be applied the day of the appoinment if you are more than 10 minutes late, and/or cancel/reschedule less than 24 hours prior to the appointment.

"I therefore accept chiropractic care on this basis"
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Parent's Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Date
Current Age
Birth weight
Birth length
Where was the baby born? (At home, hospital, birthing center)
APGAR Score
Type of birth (vaginal, cesarean, forceps, ventouse extraction)
Position of baby at birth (breech, vertex, transverse lie)
Any anesthesia or sedation applied during labor? (If yes, please list what was used)
Problems during pregnancy:
Problems during labor/birth:
Any known congenital anomalies or defects of baby?
How many bowel movements per day?
Your baby's nutrition comes from?

BreastmilkBottleBoth
If bottle, which formula?
Name of obstetrician or midwife
Name of doula
Name of pediatrician or family physician
Date of most recent medical visit

MonthDayYear
Date
What was the purpose of the medical visit listed above?
Any surgical procedures? (If yes, please list)
Is the baby on any medications? (If yes, please list)
Number of doses of antibiotics your child has taken in the past 6 months:
Number of doses of antibiotics your child has taken during his/her lifetime:
Previous Chiropractor:
Purpose of last chiropractic visit:
Has your child ever been treated on an emergency basis? If yes, please explain:
Has your baby experienced any of the following signs

Inability to sucklePoor feedingRegurgitation/refluxNasal congestion or dischargeChest congestion or coughGasping, choking, or wheezingPoor weight gainPoor sleeping patternsInconsolable cryingInability or reluctance to move a limbFavoring head rotation or head tilt to one side or the other (especially during feedings)Cranial asymmetries, molding or deformityDigestive disordersVomitingConstipationDiarrheaExcessive/painful gassinessColicAllergies, including skin reactionsHernia/rupturesHeart conditionRespiratory conditionsOrthopedic problemsNeurologic conditionConvulsionsParalysisBroken bonesKidney dysfunctionSkin problems/rashesImmunization reactions
Purpose of this appointment:
Pregnancy Health History
What was the duration of the pregnancy?
Total maternal weight gain
Ingestion of or exposure to any potentially harmful substances at any point during the pregnancy? (If yes, please list)
Use of diagnostic techniques such as ultrasound or amniocentesis, radiographs? (If yes, please list)
Any of the following complications during pregnancy?

ToxemiaGestational diabetesElevated blood pressurebleedingVomitingMalnutritionAny infectious processesOther
How was labor initiated?

ContractionInductionOther
List 3 family/friends who need to be under specific neurological-based chiropractic care. (Even if they are in another state or country)
INFORMED CONSENT FOR CHIROPRACTIC CARE

CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE

INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE.

PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE.

I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT.

I AUTHORIZE DR. SHIQUITA WHITE AND ANY AND ALL GOD FAMILY CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIOGRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD.

AS OF THIS DATE, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY GOD FAMILY CHIROPRACTIC.

Print child/minor's name and sign.
Name

First NameLast Name
Today's date

MonthDayYear
Date
Guardian's signature

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Pediatric Health History

Pregnancy Health History