Spinal Care Chiropractic New Patient Intake Form
For Patient aged 0 to 12 years old
Patient Name
*
Miss
Master
Prefix
First Name
Middle Name
Last Name
Suffix
Patient Birth Date
*
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January
February
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Year
Age:
*
Name of Parent/ Guardian
*
First Name
Last Name
Mobile Number of Parent/ Guardian
*
-
09xx
xxxxxxx
Alternate Mobile Number/ Landline
*
-
Area code or 09xx
xxxxxxxx
Parent's or Guardian's E-Mail
*
Confirmation Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Not from Metro Manila: How long are you here for?
*
Please Select
N/A
Less than 1 week
1 week
2 weeks
2-4 weeks
1-6 months
More than 6 months
Please choose N/A if you live in Metro Manila.
Not from Metro Manila: What's your average travel time?
*
Please Select
2-4 hours by car/ bus
4-8 hours by car/ bus
8-12 hours by car/ bus
12+ hours by car/ bus
1-2 hours by plane
2-4 hours by plane
More than 4 hours by plane
N/A
Please choose N/A if you live in Metro Manila.
How did you learn about the clinic?
*
Please Select
Google/ Search engine
Facebook
Instagram
YouTube
Referred
If Referred, name of person who referred you:
*
If none, write N/A
PWD Cardholder?
*
Please Select
Yes
No
.
PWD Card Number:
*
Write N/A if no ID
PWD Issue Date:
*
Write N/A if no ID
Disability Type:
Write N/A if no ID
Issued by (City):
Write N/A if no ID
Have you been to a Gonstead Chiropractor before?
*
Please Select
Yes
No
.
Do you have full spine X-Rays (A-P and Lateral)?
*
Please Select
Yes
No
.
Do you have MRI or CT Scan?
*
Please Select
Yes
No
.
Date of Scan:
Write N/A if none
Previous chiropractor?
*
Name of chiropractor and clinic or write N/A if none
Date of last chiropractic visit?
*
Write N/A if not applicable
How many sessions have you had?
*
Write N/A if not applicable
Reasons for changing chiropractors?
*
Costs (Too expensive)
Location (Too far or overseas)
Unhappy with results
Want to try other chiropractors
Not applicable
Other
Reason for consultation. List all your child's health concerns/ symptoms including description, frequency, severity, when it started, what makes it better or worse.
*
Have you consulted a medical doctor (orthopaedic surgeon, etc)
*
Please Select
Yes
No
.
What was the diagnosis?
*
Write N/A if none
What treatments has your child tried before including medications, heat/cold compress, patches, etc? If none, write N/A
*
Write N/A if none
Does your child see a Physical Therapist?
*
Please Select
Yes
No
.
How often?
*
Please Select
2-3 times per week
Once a week
2-3 times a month
Once a month
Occasionally
.
What does your PT do? (stretch, traction, etc)?
*
If none, write N/A
Other medical conditions, surgeries, accidents, trauma (including birth trauma), and falls (minor/major). Write N/A if none
*
Family medical history (including spinal issues, scoliosis, arthritis, neurological disorders, etc.). Write N/A if none
*
Is your child diagnosed with scoliosis?
*
Please Select
Yes
No
.
If yes, when was your child diagnosed
*
If No, write N/A
Date of last X-Ray?
*
If none, write N/A
Write all exercises/ sports/ activities that your child does.
*
If none, write N/A
Write all supplements your child take?
*
If none, write N/A
Tell us more about your pregnancy and birthing experience. Did you have any complications during pregnancy or delivery? Was you delivery through Vaginal (indicate how the baby presented - head, face, breech) or C-Section (planned or emergency)?
*
How many weeks gestation was your child at birth?
*
Was your child ever placed in NICU?
*
Please Select
Yes
No
Did your child spend time in any baby device such as bouncer, swing, car seat, baby carrier, sling, walker, stroller/pram? if so, what device and how many minutes/ hours per day? What's the maximum?
*
How long did your child crawl for (months)?
*
What age did your child start walking?
*
Lifestyle
*
Please Select
Active
Moderate
Sedentary
Is your child RIGHT or LEFT handed?
*
Please Select
Right
Left
Both
Child's Preferred Sleeping Position
*
Please Select
Back
Right Side
Left Side
Stomach
Changes position throughout the night
Type of Pillow used
*
Please Select
None
Soft
Medium
Firm
How long does your child sleep every night?
*
Please Select
less than 6 hours
6-9 hours
9-12 hours
12+ hours
How many pillows does your child use
*
Please Select
0
1
2 or more
Type of Mattress used
*
Please Select
None
Soft
Medium
Firm
How long is your child at school?
*
Please Select
1-3 hours
3-6 hours
6-9 hours
9+ hours
Does not go to school
Average steps (walking) per day?
*
Please Select
1-3 hours
3-6 hours
6-9 hours
9+ hours
Does not go to school
No. of hours/day on gadget?
*
Please Select
Does not use gadgets (0)
1-3 hours
3-6 hours
6-9 hours
9+ hours
Does your child slouch/ hunch when STANDING?
*
Please Select
Yes
No
Does your child carry bags/ backpacks on one shoulder/hand only
*
Please Select
Yes
No
Does your child wear foot insoles/ orthotics?
*
Please Select
Yes
No
Does your child slouch/ hunch when SITTING?
*
Please Select
Yes
No
How many hours does your child spend sitting including car rides?
*
Please Select
1-3 hours
3-6 hours
6-9 hours
9+ hours
Does your child use ergonomic chairs/ desk?
*
Please Select
Yes
No
Does your child use support pillows/ devices when SITTING?
*
Please Select
Yes
No
Does your child sit on the floor, bed, sofa or beanbag?
*
Please Select
Yes
No
Does your child use tablet, laptop or desktop?
*
Please Select
Tablet/ Ipad
Laptop
Desktop
Ipad and Laptop
Ipad and Desktop
Laptop and Desktop
All of the above
None
If using a monitor, is the screen at eye level?
*
Please Select
Yes
No
Back
Next
Please click all items that applies to your child.
*
*
*
Back
Next
Are you willing to undergo the required posture photos, gait and balance testing, and chiropractic examination?
*
Yes
No
N/A
Click N/A if child is below 4 years old.
Are you willing to undergo the required X-rays (and other medical tests)? All patients, except children aged 0–3 years and pregnant women, are required to have a full spine X-ray (A-P and lateral views) before beginning treatment. As a Gonstead chiropractic clinic, X-rays are compulsory. They serve as a vital diagnostic tool to assess the spine’s condition, including any degeneration, curvature, or congenital defects, and to corroborate findings from the initial chiropractic examination performed during your first consultation. Most importantly, X-rays guide the chiropractor in making sure that every adjustment is carried out as specific and precise as possible. For this reason, X-rays are required regardless of whether you already have MRI results or have previously received chiropractic adjustments elsewhere. Strictly no X-rays, no adjustment. If your child is aged 0-3 years old, click N/A.
*
Yes
No
N/A
Unsure
If unsure or unwilling to have X-Rays done, please state reason why:
*
Child is below 4 years old
Radiation concerns
Just recently had one (within 6 months)
Already have required X-Rays
Don't see the need for X-Rays
What's your purpose or goals for seeking chiropractic care?
*
1. For chiropractic evaluation or second opinion only. Unsure if willing to proceed with treatment.
2. Trial chiropractic care (maximum 1-2 sessions)
3. Short-term/ symptoms relief
(maximum 6 sessions)
4. Spinal correction/ postural changes
5. Prevent spinal osteoarthritis/ spondylosis
6. Regular maintenance care of your spine
What activities can't your child to do now that you'd like them return to?
*
Please Select
Travel
Sports
Hobbies
Daily Activities
How often can you come for adjustments?
*
Please Select
As recommended by chiropractor
Once a week
2-3 times a month
Once a month
Once a quarter
I only want 1-2 sessions
Others
Terms and Conditions
SPINAL CARE CHIROPRACTIC is a chiropractic clinic specializing in the Gonstead technique.During your initial consultation, our goal is to provide a thorough assessment of your child's spinal health and guide you toward a sustainable plan for achieving your health goals and maintaining a healthy nervous system. Please note that we are not a medical clinic, hospital, or physical therapy rehabilitation center. All chiropractic adjustments are performed only by a registered and licensed chiropractor. Before recommending any treatment, our chiropractors will carefully evaluate your child's suitability for chiropractic care through consultation, examination, and X-ray analysis. Not all patients will be advised to undergo chiropractic adjustments. It is the patient’s responsibility to fully disclose all known medical history and health concerns during the consultation. Any findings will be clearly explained before starting care, and you will be given the opportunity to ask questions and discuss potential risks associated with chiropractic treatment. The decision to provide treatment on the same day as the initial consultation is at the discretion of the chiropractor and is generally reserved for patients who do not require X-rays, such as young children (below 4 years old) and pregnant women. Treatment may only begin once all required X-rays or other medical tests have been submitted, reviewed, and analyzed by our chiropractor.
Overview of Chiropractic Care and Chiropractors
Chiropractors are university-trained, licensed healthcare professionals who specialize in spinal health and the treatment of musculoskeletal conditions through safe and precise manual techniques. They are trained to detect and correct subluxations (spinal misalignments) and often receive more extensive training in spinal manipulation than other practitioners, making them experts in this field.In addition to adjustments, chiropractors are trained to diagnose and manage a wide range of conditions with an emphasis on spinal and nervous system function. They may use various diagnostic tools, including X-rays, and often take a holistic approach, addressing not just symptoms but also the underlying causes. Chiropractors can also provide lifestyle advice, nutrition guidance, ergonomic recommendations, and specific exercises or stretches to support overall well-being.There are many chiropractic techniques, and Gonstead, which our chiropractor specialize in, is one of the most precise. Techniques differ not only in how adjustments are performed but also in how chiropractors examine, analyze, and manage each case. While continuing care with a different chiropractor is possible, the quality of care and methods used may vary.Chiropractic care typically requires multiple sessions over time to achieve lasting results. Some patients may feel immediate relief after their first adjustment, but this is often temporary. Long-term improvement requires consistency and patience, especially for chronic issues which generally take longer to resolve than acute conditions. Because adjustments are done manually, repeated sessions are needed to create structural changes and stability in the spine.Outcomes vary from person to person, influenced by factors such as age, lifestyle, current spinal condition, overall health, genetics, compliance with recommendations, and the chiropractor’s experience. As with any form of healthcare, medical, pharmaceutical, or otherwise, results cannot be guaranteed due to these variables. Similarly, the number of sessions needed will differ for each individual.Finally, it’s important to understand that chiropractic care addresses current problems but does not permanently “fix” the spine for life. Normal aging, daily activities, stress, trauma, or accidents can all contribute to new issues over time. For this reason, regular chiropractic care is often necessary to maintain spinal health, prevent recurrence, and support overall wellness.
Fees and Termination of Treatment
All consultation and treatment fees will be charged based on the current price list and must be settled on or before the day of the appointment. Fees for the initial consultation, follow-up consultations (including X-ray reports), and treatments are billed separately. X-ray report consultations are charged independently due to the time required to analyze X-rays and prepare a personalized treatment plan. Please note that all payments are non-refundable. If you choose not to proceed with follow-up consultations or treatments, you are required to collect your child's CDs or films within three (3) months from your last appointment. Failure to do so will be deemed as granting Spinal Care Chiropractic Inc. permission to dispose of these records without further confirmation from you or your next of kin. Any unused treatment sessions under a package may be transferred to another individual of your choice. However, all packages must be fully consumed before their stated expiry date, regardless of whether they remain with the original patient or have been transferred to another person. It is the patient’s responsibility to assign and ensure the use of any remaining sessions should they decide to discontinue treatment.
Training Goals and Purpose
You may be asked to answer questionnaires or be interviewed regarding you or/your child's experience. With the exception of relevant identifying details such as name, address, contact details, all information provided may be used for research and training goals of Spinal Care Chiropractic Inc. and their chiropractors.
Recordings and Observations
As part of Spinal Care Chiropractic’s assessment protocols, video recordings and photographs may be taken. These are used primarily for assessment, progress tracking, and case study purposes. If recordings are to be used for any other purpose, the patient’s guardian's explicit permission will be obtained beforehand. Please note that any third-party video recording or photography of sessions, whether online or in person, requires prior approval. The sharing or posting of such recordings, including on social media or other online platforms, is strictly prohibited.
Consent, Waiver, and Release
By submitting this form and affixing your signature, you grant Spinal Care Chiropractic Inc. permission to collect yours and your child's personal data for the purpose of conducting a chiropractic evaluation. You also consent for your child to undergo a chiropractic assessment, which may include history taking, postural and gait analysis, and other relevant examination procedures. Verbal agreement to begin treatment, whether on the day of consultation or at a later date, constitutes your authorization for our chiropractor to perform chiropractic adjustments or other appropriate treatment procedures as required. Consent to receive treatment signifies your full understanding and acceptance of the treatment plan, its possible outcomes, and the associated risks. It also constitutes a waiver and release of all claims against Spinal Care Chiropractic Inc., including its officers and employees, arising from the treatments provided.Submission of this form confirms your consent and agreement to all terms and conditions stated herein.
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