RLC Pediatric New Patient Form

Pediatric New Patient Form
Please enter child's information
Name*

First NameMiddle NameLast Name
Birthday*

MonthDayYear
Date
Preferred Name
Social Security #
Gender*

FemaleMale
Address*

Street Address

Apt./Unit #:

CityState / Province

Postal / Zip Code
# of Siblings
Sibling(s) Names & Ages:
Parents' Names:
Best Contact Name:
Phone Number
Please enter a valid phone number.
Alternate Contact Name
Phone Number
Please enter a valid phone number.
Text Reminders:

YesNo
Email*
example@example.com
How did you hear about Restoring Life Chiropractic?
CHECK ALL THAT APPLY

Social MediaFriend/Co-workerIn-Office WorkshopCurrent PatientLive/Work NearbyOnline WebinarInternet SearchAnother ProviderOther
If Friend/Co-worker, enter name
If Current Patient, enter name
If Another Provider, enter name
If Other, please specify
Reason for Seeking Care
What is your reason for seeking care at Restoring Life Chiropractic?
When did this begin? (If applicable)
Are there any major injuries, surgeries, and/or hospitalizations we should know about?
What is this affecting that is MOST important in your child's life and your life? (List all that apply)
Has your child seen any other providers for this condition? (List all that apply)
Has your child seen a chiropractor before?

YesNo
How long ago?
Clinic/Doctor Name:
What is your reason for the change? (If applicable)
What health goal, if your child were to complete or accomplish it, would have the greatest impact on his or her life?
Health Concerns for Patients 0-5 years of age (If not applicable, skip this section)

Breast-feeding difficultyConstipationGas/IndigestionTongue tieColic/Acid RefluxFlat Spots on HeadDifficulty Gaining WeightAsthmaSeasonal/Environmental AllergiesAutism/Asperger'sDevelopmental DelayFrequent SicknessNauseaNomitingChronic Bronchitis/Breathing TroublesBedwettingSensory IssuesBehavioral IssuesDiarrheaEar InfectionsHead PreferenceFatigue/Sleep IssuesSinus InfectionsFood AllergiesADD/ADHDDetachment/DistantLearning DisordersOther, please indicate:
Health Concerns for Patients 6-10 years of age (If not applicable, skip this section)

Fatigue/Sleep IssuesSinus InfectionsChronic Bronchitis/Breathing TroublesDiarrheaBedwettingFood AllergiesDepressionDetachment/DistantLearning DisordersHeadaches/MigrainesFrequent SicknessSeasonal/Environmental AllergiesDiabetesGas/IndigestionOverweightAcid RefluxADD/ADHDBehavioral IssuesSensory IssuesBack Pain/StiffnessEar Infections/TubesAsthmaConstipationNausea/VomitingDifficulty Gaining WeightAnxietyAutism/Asperger'sIrritability/NervousnessGrowing PainsNeck Pain/StiffnessOther, please indicate:
Health Concerns for Patients 11-17 years of age (If not applicable, skip this section)

Frequent SicknessFatigue/Sleep IssuesDiabetesAsthmaMenstrual difficultiesSeasonal/Environmental Al lergiesGas/IndigestionDifficulty Gaining WeightAnxietyDepressionBehavioral IssuesHeadaches/MigrainesAcne/Dry skin/Redness/Skin issuesConstipationNauseaNomitingOverweightADD/ADHDDetachment/DistantSensory IssuesBack Pain/StiffnessEar Infections/TubesChronic Bronchitis/Breathing TroublesSinus InfectionsDiarrheaIncontinenceFood AllergiesAutism/ Asperger'sIrritability/NervousnessAchy MusclesNeck Pain/StiffnessOther, please indicate:
Explain any boxes checked above:
Is there anything else regarding your child's current condition you feel the doctor should know?
Medications

AnxietyMigraine/HeadacheADD/ADHDMuscle RelaxersBirth ControlAllergy MedicationsBlood PressureDiabetesGas DropsPain MedicationsDepressionOther, please indicate:
Explain any boxes checked above:
Vitamins / Supplements

Multi-VitaminMagnesiumFish Oil/Omega-3Vitamin D3ProbioticsOther, please indicate:
Prenatal History for Patients under 10 years of age (If not applicable, skip this section)
Location of birth:

HomeHospitalBirthing CenterOther, please indicate:
Did you receive Chiropractic care during your pregnancy?

YesNo
Explain
Did any of the following happen during delivery:

Labor was inducedPlanned C-section deliveryEmergency C-section deliveryAnesthesiaSpecial medical procedures/testsForceps/vacuum extractionDoctor pulled or twisted babyDPremature delivery
Describe any of the above plus any additional complications experienced during delivery:
During pregnancy, did you experience any illness, complications and/or concerns?

YesNo
Please explain:
Birth
Birth weight:
Birth length:
APGAR scores (if remembered):
Ultrasound used during pregnancy?

YesNo
Number of times:
Did /do you breastfeed the baby?

YesNo
How long:
Did/do you formula-feed the baby?

YesNo
How long:
At what age did you introduce:
Solids:
Cow's milk:
Tummy Time?
Age started
Difficulty

YesNo
Crawling/Walking?
Age started
Difficulty

YesNo
Difficulty Sleeping?

YesNo
Lifestyle Habits for Patients over 5 years of age (If not applicable, skip this section)

Does your child......
Exercise daily?

YesNo
How much?
Have a positive self-esteem or self-image?

YesNo
Play video games or watch TV for more than one hour per day

YesNo
How much?
Eat balanced meals?

YesNo
Experience prolonged sadness?

YesNo
Explain
Have difficulty sleeping?

YesNo
Explain
Current Health Status
The National Safety Council reports approximately 50% of children fall head first from a high place during their first year of life (bed, changing table, stairs, etc.). Was this the case for your child?

YesNo
Explain
Does your child have difficulty interacting with others?

YesNo
Explain
Have you noticed that your child is nervous, twitches, shakes, or exhibits rocking behavior?

YesNo
Explain
Has your child been involved in any high impact/contact sports (soccer, football, martial arts, cheerleading, etc.)?

YesNo
Please list:
Are you aware of any food allergies or intolerance?

YesNo
Explain
Has your child received all recommended vaccinations?

YesNo
Explain
Please rate stress levels on a scale of 1-10 (10 being highest)
School
Personal
Informed Consent for Chiropractic Care
I hereby authorize the doctors and staff at Restoring Life Chiropractic to treat my condition as deemed appropriate. At Restoring Life Chiropractic, we do not diagnose or treat any disease or condition other than vertebral subluxation and the doctors/clinic will not be held responsible for any pre-existing medical conditions. I certify that the above information is correct to the best of my knowledge. I will not hold the doctors or any staff member of Restoring Life Chiropractic responsible for any errors or omissions that I may have made in the completion of this form. Chiropractic, as well as all other types of health care is associated with potential risks in the delivery of treatment. While chiropractic treatment is remarkably safe, you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment. Please inquire if you have further questions. Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition, or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal, and if the results are not acceptable, we will refer you to another provider who we feel can further assist you.
Signature*

Clear
Date Signed*

MonthDayYear
Date
Printed Name*
Email*
example@example.com
Patient HIPAA Consent Form
Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view charges to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff.

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician's certificates. I have read and understand your Notice of Privacy Practices. I also understand that I can request in writing that you restrict how my personal information is used and disclosed.
Patient Name
Signature*

Clear
Date Signed*

MonthDayYear
Date
Printed Name*
Email*
example@example.com
PHOTOGRAPHY RELEASE
At Restoring Life Chiropractic we love to document and share special moments in our office. We do this through photography, video, and story telling in order to share testimonies about life and chiropractic with our community so that people may have HOPE for better health and quality of life. Thank you for being a part of our chiropractic community and helping us help others.
Permission to Use Photographs for the following individuals:
I grant to Restoring Life Chiropractic, its representatives and employees the right to take photographs and video of me and my property in connection with chiropractic care. I authorize Restoring Life Chiropractic, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Restoring Life Chiropractic may use such photographs and video of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Name:*
Signature:*

Clear
Date:*

MonthDayYear
Date
PERMISSION TO TREAT A MINOR
I, give Restoring Life Chiropractic permission to examine, x-ray (if necessary), and treat (insert name): Minor date of birth: Date
Signature*

Clear
Date Signed*

MonthDayYear
Date
Printed Name*
Email*
example@example.com
Should be Empty:

Pediatric New Patient Form

Please enter child's information

Informed Consent for Chiropractic Care

Patient HIPAA Consent Form

PHOTOGRAPHY RELEASE

PERMISSION TO TREAT A MINOR