New Patient Health History Intake Form - Child
Full Name
*
First and Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Birthdate
*
-
Month
-
Day
Year
Date
Age
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
Cell Phone
Work Phone
Gender
Male
Female
Significant Other's Name
Kid's Names and Ages
Your Employer
Type of Work
E-Mail Address
Have you been to a chiropractor before?
No
Yes
Emergency Contact
Emergency Contact Phone Number
Name of Medical Doctor(s)
Name of Insurance Provider
For my balance my preferred payment method is:
Cash
Check
Credit Card
Car Insurance/Work Comp Insurance
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:
Dull
Sharp
Ache
Numb / Tingle
Stabbing
Is your symptom:
Constant
Occasional
Is your symptom:
Staying the same
Getting worse
Is your symptom:
Mild
Moderate
Severe
Is your symptom:
Worse in the morning
Worse in the evening
Does your pain radiate?
Yes
No
If yes, where does your pain radiate?
PRESENT COMPLAINT #2 (if applicable)
How long has this been an issue?
Is your symptom:
Dull
Sharp
Ache
Numb / Tingle
Stabbing
Is your symptom:
Constant
Occasional
Is your symptom:
Staying the same
Getting worse
Is your symptom:
Mild
Moderate
Severe
Is your symptom:
Worse in the morning
Worse in the evening
Does your pain radiate?
Yes
No
If yes, where does your pain radiate?
PRESENT COMPLAINT #3 (if applicable)
How long has this been an issue?
Is your symptom:
Dull
Sharp
Ache
Numb / Tingle
Stabbing
Is your symptom:
Constant
Occasional
Is your symptom:
Staying the same
Getting worse
Is your symptom:
Mild
Moderate
Severe
Is your symptom:
Worse in the morning
Worse in the evening
Does your pain radiate?
Yes
No
If yes, where does your pain radiate?
PRESENT COMPLAINT #4 (if applicable)
How long has this been an issue?
Is your symptom:
Dull
Sharp
Ache
Numb / Tingle
Stabbing
Is your symptom:
Constant
Occasional
Is your symptom:
Staying the same
Getting worse
Is your symptom:
Mild
Moderate
Severe
Is your symptom:
Worse in the morning
Worse in the evening
Does your pain radiate?
Yes
No
If yes, where does your pain radiate?
Please mark all areas of concern:
Does your condition affect (Select all that apply):
Sleep
Work
Daily Routine
Sitting
Driving
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?
Yes
No
GENERAL HEALTH HISTORY
Please mark any conditions you have experienced in the past or present:
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:
-
Month
-
Day
Year
Date
Reason for last doctor's visit:
Name of Obstetrician/Midwife
Location of Birth:
Hospital
Birthing Center
Home
Complications During Pregnancy:
No
Yes
If complications during pregnancy, please explain:
Ultrasounds During Pregnancy:
No
Yes
Number of ultrasounds during pregnancy:
Medications During Pregnancy / Delivery:
No
Yes
Please list any medications taken during pregnancy / delivery:
Cigarette / Alcohol Use during pregnancy:
No
Yes
Has any Doctor or Other Professional advised you to "Take the child to a Chiropractor":
No
Yes
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:
Heart Disease
Cancer
Diabetes
Heavy Medication Use
Arthritis
Other
If other history on father's side, please describe:
Family history mother's side:
Heart Disease
Cancer
Diabetes
Heavy Medication Use
Arthritis
Other
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.
*
Ready to submit
Preview PDF
Submit
Should be Empty: