New Patient Intake Paperwork

New Patient Health History Intake Form - Child
Full Name
First and Last Name
Today's Date

MonthDayYear
Date
Birthdate

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Gender
Significant Other's Name
Kid's Names and Ages
Your Employer
Type of Work
E-Mail Address
Have you been to a chiropractor before?
Emergency Contact
Emergency Contact Phone Number
Format: (000) 000-0000.
Name of Medical Doctor(s)
Name of Insurance Provider
For my balance my preferred payment method is:
Person responsible for this account if other than the patient?
- I authorize the doctor or his staff to render care as deemed appropriate for me and / or my child.
- I authorize the Total Spine staff to request records from other providers as may be necessary.
- I understand I am responsible for all bills incurred in this office.
- I authorize assignment of my insurance benefits (if applicable) directly to the provider.
- I understand that after any initial promotional services all care is rendered at usual and customary fees.
Patient/Parent Signature
REASON FOR SEEKING CARE

Please describe your primary complaint in the space below. Use the additional complaint boxes if they apply.
PRESENT COMPLAINT #1
How long has this been an issue?
Is your symptom:
Is your symptom:
Is your symptom:
Is your symptom:
Is your symptom:
Does your pain radiate?
If yes, where does your pain radiate?
PRESENT COMPLAINT #2 (if applicable)
How long has this been an issue?
Is your symptom:
Is your symptom:
Is your symptom:
Is your symptom:
Is your symptom:
Does your pain radiate?
If yes, where does your pain radiate?
PRESENT COMPLAINT #3 (if applicable)
How long has this been an issue?
Is your symptom:
Is your symptom:
Is your symptom:
Is your symptom:
Is your symptom:
Does your pain radiate?
If yes, where does your pain radiate?
PRESENT COMPLAINT #4 (if applicable)
How long has this been an issue?
Is your symptom:
Is your symptom:
Is your symptom:
Is your symptom:
Is your symptom:
Does your pain radiate?
If yes, where does your pain radiate?
Please mark all areas of concern:
Does your condition affect (Select all that apply):
What makes your symptoms better?
What makes your symptoms worse?
What Doctor's have you seen for this?
What type of treatment have you received?
Results of treatment?
Anything additional regarding your current condition:
Are you pregnant?
GENERAL HEALTH HISTORY

Please mark any conditions you have experienced in the past or present:

Rows	Past	Present
Headaches
Ear Infections
Colic
Allergies / Asthma
Medication Side Effects
Recurring Fevers
Digestive Problems
Bed Wetting
Chronic Colds/Sinus
Vision Problems
Sleeping Problems
Growing Pains
Dental Problems
Temper Tantrums
ADHD
Seizures
Scoliosis
Ever Needed Stitches
Other

If other history, please describe:
Type a question
Number of courses of Antibiotics child has taken in the last 6 months:
Total Antibiotics child has taken during lifetime:
Name of Pediatrician and Other Doctors:
Date of last doctor's visit:

MonthDayYear
Date
Reason for last doctor's visit:
Name of Obstetrician/Midwife
Location of Birth:
Complications During Pregnancy:
If complications during pregnancy, please explain:
Ultrasounds During Pregnancy:
Number of ultrasounds during pregnancy:
Medications During Pregnancy / Delivery:
Please list any medications taken during pregnancy / delivery:
Cigarette / Alcohol Use during pregnancy:
Has any Doctor or Other Professional advised you to "Take the child to a Chiropractor":
If yes, name of Doctor or professional:
PAST HISTORY
List any past auto collisions:
Auto collisions: Was any care received?
List any past falls, bumps, bruises:
Falls, bumps, bruises: Was any care received?
List any past sport, recreational, or home injuries:
Please describe any past conditions and treatment received:
Please list any past hospitalizations and surgeries:
FAMILY HISTORY
Family history father's side:
If other history on father's side, please describe:
Family history mother's side:
If other history on mother's side, please describe:
Is there any other family history you want us to know?
Please check the box when you are ready to submit.
Should be Empty:

New Patient Health History Intake Form - Child

REASON FOR SEEKING CARE

GENERAL HEALTH HISTORY

PAST HISTORY

FAMILY HISTORY