Foundation Chiropractic - Adult History Form

Prenatal History
Name of Obstetrician/ Midwife:*
Complications during pregnancy/ delivery? Y/N Explain:*
Ultrasounds during pregnancy? Y/N How many?*
Medications taken during pregnancy/ delivery? Y/N List:*
Cigarette/ Alcohol use during pregnancy?*
Location of birth*
Birth Intervention*
If Caesarian Section, was it
Genetic disorders/disabilities? Y/N List:*
Birth Weight:*
Birth Length:*
APGAR Scores:*
Feeding History
Breast Fed: Y/N How long?*
Formula Fed: Y/N How long? What type?*
At what age, in months, were the following things introduced?
Solid Foods*
Cow’s milk*
Food/ Juice allergies or intolerances: Y/ N List:*
Developmental History (to the best of your knowledge)
Your child’s spine is vulnerable to stress and should routinely be checked by a doctor of chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference). Spinal nerve interference can affect the following. At what age, in months, was your child able to:
Respond to stimuli*
Respond to visual stimuli *
Sit up*
Cross Crawl*
Hold head up*
Stand alone*
Walk alone*
According to the National Safety Council, approximately 50% of children fall head first from a high place during their first year of life (i.e. a bed, changing table, down stairs)
Did your child have a fall similar to what was described above?Y/N Explain:*
Other traumas not described above (bike wipeout, trampoline injury, etc.)?*
Has your child been involved in any sports? Y/N List:*
Has your child been seen by a physician on an emergency basis? Y/N Explain:*

Lifestyle
Does your child (please check all that apply):*

eat healthy food (organic products, etc.)drink watertake probioticstake vitamins
If they take vitamins, what type?
Exercise:*

nonemildmoderateheavydaily
Hobbies/ interests:*
Is there anything else you would like us to know about your child?*
Parent/Guardian Name*

First NameLast Name
Signature

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We love to have kid’s pictures in our office! If you would allow us to have your child’s picture in the office, please sign below.
For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by Foundation Chiropractic Inc., or anyone authorized by Foundation Chiropractic Inc., of any and all photographs/videos which were taken of my child, for the purposed of promotional TV, website, social media and/or print ad whatsoever, without further compensation to me. All negatives and positives, together with the prints shall constitute the property of Foundation Chiropractic Inc., solely and completely. Any information voluntarily provided by a patient shall also be used in conjunction with the above listed information for purposes previously mentioned. Confidentially, in regards to any reported conditions, is also
waived to the extent of information pertinent to the promotion material only. I authorize Foundation Chiropractic Inc. to share this information via their website and their Facebook/social media including Twitter and Instagram, and for use in the office. All other unrelated patient information shall remain private and protected (according to Health Information and Privacy Act laws).
Signature*

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Date

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Date

Terms & Conditions

In the event that you do not move forward with recommendations any credits not utilized within 30 days of your last visit to Foundation Chiropractic will entirely become the property Foundation Chiropractic.

In the event that you do not move forward with recommendations any credits not utilized within 30 days of your last visit to Foundation Chiropractic will entirely become the property Foundation Chiropractic.

X-RAY AUTHORIZATION
AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR
CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES. AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF THE X-RAYS IN OUR FILES.

PLEASE NOTE: IF X-RAYS ARE NECESSARY, THEY ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTORS OF FOUNDATION CHIROPRACTIC INC. DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE.

IF YOUR CHILD IS AN INFANT OR UNDER THE AGE OF FIVE, IT IS UNLIKELY THEY WILL NEED CHIROPRACTIC POSTURAL XRAYS. HOWEVER, PLEASE SIGN BELOW FOR FUTURE REFERENCE.

BY SIGNING BELOW, YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS
Child's Name*

First NameLast Name
Child's Age*
Parent/Guardian Signature*

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Date

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Date
Should be Empty:

PEDIATRIC HISTORY FORM

Family History

Prenatal History

Feeding History

At what age, in months, were the following things introduced?

Lifestyle