Chiro Wellness Generic

CHIROPRACTIC INTAKE & HISTORY

Parent Information

Pediatric Section

PATIENT INFORMATION

Who may we thank for referring you?

Patient Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Employer / School

Occupation

Spouseʼs Name

First NameLast Name

Spouseʼs Employer

Spouseʼs Occupation

Best Time/Way to Contact You

Days(check all that apply)

Time(check all that apply)

Way to Contact You(check all that apply)

Sex

Other

Date of Birth

Date

Age Category

Mother's Name

Mother's occupation

Mother's phone

Mother's email

Father's name

Father's occupation

Father's phone

Father's email

Marital Status

Are you currently pregnant?

Iʼm due

Number of past pregnancies?

How many children do you have?

Childrenʼs health concerns?

IN CASE OF EMERGENCY, CONTACT

Name

First NameLast Name

Relationship

Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

INSURANCE

Insurance Company

Would you like us to check on your insurance?

HOW CAN WE HELP YOU?

What brings you in today?

If you are already experiencing a symptom, what is it?

How bad is it? How intense are your symptoms? (circle one)

What does it feel like? (check all that apply)

If other selected, please explain

Is Your Condition:

What aggravates your condition?

Please circle areas where you have pain or other symptoms:

Please check all symptoms you have ever had, even if they do not seem related to your current problem.

If other selected, please list other symptoms

Now please check all symptoms that you CURRENTLY are experiencing

If other selected, please list other symptoms

Has your child been treated on an emergency basis?

If yes, please describe

MOTHER'S PREGNANCY EXPERIENCE

Did you experience any complications during your pregnancy? (Check all that apply)

Please describe if you selected other

BIRTH HISTORY

Type of Birth (check all that apply)

Did you experience problems during labor/delivery? If so, please describe.

Other, please describe

GROWTH & DEVELOPMENT

Infant Feeding:

Number of hours of sleep:

Quality of Sleep:

At what age did your child:

Respond to Sound:

Crawl:

Hold Head Up:

Stand:

Sit Unsupported:

Walk Unsupported:

CHILDHOOD DISEASES, ILLNESSES, & VACCINATIONS

Has your child had any of the following (check all that apply)

Has your child suffered from: (check all that apply)

Other, please describe

Have you vaccinated your child?

HEALTH CONCERNS

Please list any other health concerns

IMPACT OF YOUR SYMPTOMS

How is this symptom / condition interfering with your life? (check where appropriate)

Rows	NO EFFECT	MILD EFFECT	MODERATE EFFECT	SEVERE EFFECT
Work / School
Exercise
Recreation
Sleep
Self Care
Energy
Relationships
Attitude
Patience
Productivity
Creativity
Other

If you selected other, please list activity

How committed are you to correcting this issue?

HEALTH & ILLNESS HISTORY

Please check the box beside any conditions that you have now or have ever had in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

Have you had any surgeries, broken bones, auto accidents, or injuries? If so, when?

Rows	SURGERY / BROKEN BONE / ACCIDENT / INJURY	Date
1
2
3

ALLERGIES, MEDICATIONS & SUPPLEMENTS

Please list all allergies you have and medications and supplements you currently take

Rows	ALLERGIES (list)	MEDICATIONS (list)	SUPPLEMENTS (list)
1
2
3
4

STRESSORS

Because accumulation of stress affects our health and ability to heal, please list your top three stresses (you have ever had) in each category:

Physical stressors (accidents, falls, hours sitting per day, repetitive postures/motions, work related habits, etc.)

a.

b.

c.

How is your current physical stress?

Bio-chemical stress (smoke, unhealthy foods, missed meals, dehydration, drugs/alcohol, etc.)

a.

b.

c.

How is your current bio-chemical stress?

Mental/emotional stress (work, relationships, finances, self-esteem, etc.)

a.

b.

c.

How is your current mental/emotional stress?

On a scale of 1-10 (1 being very poor and 10 being excellent), please grade your present levels of stress:

At work:

At home:

At play:

On a scale of 1-10 (1 being very poor and 10 being excellent), please describe your:

Eating habits:

Exercise:

Sleep:

General health:

Water consumption:

Stress level:

PATIENT WELLNESS ASSESSMENT

What number do you think represents your health today?

In what direction is your health currently headed?

What are your health goals?

Immediate

Short Term

Long Term

Things I do currently to support my health include:

Please indicate which of these you do/have on a consistent basis:

This office conforms to the current HIPPA information privacy guidelines. You may request a copy of our HIPPA policy at the front desk at any time. Please check to indicate you have been made aware of its availability.

Print Patient Name:

First NameLast Name

Parent or Guardian Name

First NameLast Name

Date:

Date

Signature:

CANCELLATION POLICY
Our goal is to provide quality health care to all our patients in a timely manner. When you book your appointment, you are holding a space on our calendar that is no longer available to other patients. In order to be respectful of other fellow patients, please call our office as soon as you know you will not be able to make your appointment. If cancellation is necessary, we require that you call at least 24 hours in advance. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time.

Our Policy:

We require a payment of $47 to hold your appointment.
Any cancellation made less that 24 hours in advance will result in this fee being non-refundable
In the event of a true, unavoidable emergency, all or part of your cancellation fee may be applied to future services.

Agreement

Please list any other health concerns according to severity

Rate of severity 1 = mild 10 = worst imaginable

When did this start?

If you had this condition before, when?

Did the problem begin with an injury?

% of the time pain is present