New Patient Form

Spinal Care Chiropractic New Patient Intake Form

For Patient aged 0 to 12 years old
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Name of Parent/ Guardian*

First NameLast Name
Mobile Number of Parent/ Guardian*

09xxxxxxxxx
Alternate Mobile Number/ Landline*

Area code or 09xxxxxxxxxx
Parent's or Guardian's E-Mail*

Confirmation Email
How did you learn about the clinic:*
If Referred, please indicate name of person who referred
Where does your child live (city of residence)?*
If you live outside Metro Manila, how long is your child here for?*
Please choose N/A if you live in Metro Manila.
How often can your child come for treatments/ chiropractic adjustments?*
A personalized treatment plan will be given to you after an extensive chiropractic evaluation and X-Ray analysis.
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 resultsWant to try other chiropractorsNot applicableOther
Child's Preferred Sleeping Position*
Is your child RIGHT or LEFT handed?*
Lifestyle*
What's your purpose or goals for seeking chiropractic care?*
Reason for consultation. List all your child's health concerns/ symptoms including description, frequency, severity, when it started, what makes it better or worse.*
What treatments has your child tried before including medications? If none, write N/A *
What supplements does your child take regularly? If none, write N/A *
Please list down all exercises/ sports/ stretches that you currently do. If none, write N/A*
Other medical conditions, surgeries, accidents, trauma (including birth trauma), and falls (minor/major). Write N/A if none*
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?*
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?*
How long does your child sleep every night?*
How many hours does your child spend sitting?*
Does you child go to school? For how long?*
How many hours a day does your child spend on gadgets/ devices?*
Describe your child's bed/ pillow and SLEEPING POSTURE. How many pillows does your child use? What type (indicate if soft or firm)? Is your child's mattress soft or firm? When sleeping, does your child move/ flip from one position to another? *
Describe your child's STANDING POSTURE. Does your child slouch or hunch over when standing? Does your child regularly carry a backpack (how heavy)? Does your child carry a bag on one shoulder or arm/hand only?*
Describe your child's SITTING POSTURE. Does your child sit for more than 1 hour at a time? Does your child use any support pillows/ devices? Does your child slouch? Does your child regularly sit on the floor (with legs stretched, Indian sitting or sitting on calves), bed, soft sofa/ La-Z-Boy, or beanbag?*
Describe your child's STUDY AREA. What type of desk and chair does your child regularly uses (is it ergonomic, height adjustable)? Does your child regularly use a tablet (or IPAD), laptop, or desktop? If using a monitor, is the center of the screen at eye level?*

Please click all items that applies to your child.

Terms and Conditions

SPINAL CARE CHIROPRACTIC is a chiropractic clinic that specializes in the Gonstead technique. Our goals for the initial consultation are to provide a detailed assessment of your child's current spinal condition and provide you with a guide to a sustainable approach to reaching your child's health goals and achieving a healthy nervous system. We are not a medical clinic, hospital nor a physical therapy rehab center. All chiropractic adjustments are performed by a registered and licensed chiropractor. Our chiropractors will assess patient's suitability in receiving chiropractic adjustments prior to recommending treatments. Not all patients will be advised to undergo chiropractic treatments and would depend on the initial consultation, chiropractic evaluation and X-ray analysis. It is the patient's responsibility to disclose all known medical history and concerns during the consultation. Any findings will be communicated before commencement of care. Patient's parent/s or guardian will be given enough opportunity to discuss concerns regarding the recommended treatments including possible risks involved in chiropractic care before commencement of care. The decision to grant a patient's request to have treatment the same day as the initial consultation is at the discretion of the chiropractor and only reserved for special circumstances. Treatment may only start once patient has submitted all necessary X-Rays or other medical tests required and after these tests have been carefully evaluated and analyzed by our chiropractor.
Overview of Chiropractic Care and Chiropractors

Chiropractors are university-trained healthcare professionals specializing in spinal health and treating musculoskeletal conditions through manual techniques. They are trained to detect and treat subluxations or spinal misalignments. They often have more extensive training in spinal manipulation techniques than others, making them experts in this field. There are also trained to diagnose and treat a wide range of conditions with an emphasis on spinal issues and may use different diagnostic tools including X-ray. Chiropractors often has a holistic approach to care and would not just treat symptoms buy also address underlying causes. They can also provide lifestyle advice, nutrition guidance, ergonomic recommendations and exercises/ stretches to support overall wellbeing. Chiropractors are also licensed healthcare professionals. There are different chiropractic techniques and Gonstead, which our chiropractors specialize in, is one of them. Different techniques differ not just on how the adjustments are done but also on how each chiropractor examines, analyzes, and manages the condition of the patient. Continuing care with a different chiropractor is possible but understand that the quality of care will also be different. Chiropractic care often requires multiple sessions over time for optimal results. Some individuals may experience instant relief on the first adjustment; however, this is temporary. To experience the full benefit of chiropractic care requires patience and consistency. As the adjustments are done manually, it requires multiple sessions to have longer lasting effect and changes in the spine’s condition. Chronic issues take longer to resolve than acute ones. Results of chiropractic care varies from person to person because a lot of factors affect the results including age, lifestyle, current spine condition, consistency of care, current health of the patient, genetics, compliance to recommendations and the skills and experience of the chiropractor treating the patient. Like any other treatment (even medical or pharmaceutical), results can never be guaranteed because of the number of factors that affect results. Likewise, the number of sessions required varies from person to person. Furthermore, as the body ages and due to normal daily activities, stress, trauma or accidents, there is a continuous need for regular chiropractic care. Chiropractic care may fix or resolve a symptom, but it doesn’t mean it will be fixed for life due to normal wear and tear of the body. The constant movement of the body may cause problems to come back over time or for others to appear.
Fees and Termination of Treatment

Consultation and treatment fees will be charged accordingly (as per current price list) and must be settled on or before the day of appointment. Fees for initial consultation, followup consultations (including X-Ray report), and treatments are all separately billed. X-Ray report consultations are billed separately due to the time involved analyzing the X-Rays as well as creating a customized treatment plan for each patient. Strictly no refunds will be issued. TERMINATION OF TREATMENT OR FOLLOW-UP CONSULTATION: Should you decide not to pursue follow-up consultations or treatments, kindly collect your child's CDs or films within three (3) months from your child's last appointment. Failure to collect within the specified time automatically grants Spinal Care Chiropractic Inc. permission to destroy the records on your behalf without need for further confirmation and instructions from the patient or next of kin. Any unused treatment sessions in the patient's package may be transferred to another person of the patient's choice. It will be the patient's responsibility to assign the unused portion of their package should they decide to stop treatments.
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 will be taken. These will be used for assessment and progress tracking purposes as well as case studies. Should these videos be used for other purposes, patient's permission will be sought. Third party video recording or photography of the sessions, both online or in person, will be subject for approval and subsequent sharing of said recordings (including posting online) is strictly prohibited,
Consent, Waiver, and Release

By submitting this form and affixing your signature, you hereby grant Spinal Care Chiropractic Inc. permission to collect personal data from you for the purpose of conducting patient evaluation. You also hereby grant permission for your child to receive a chiropractic evaluation including history taking, postural and gait analysis and other pertinent examination procedures. Verbally agreeing to start treatment whether on the day of consultation or not, automatically grants our chiropractor the permission to perform chiropractic adjustments or other appropriate forms of treatment as required. Consent to receive treatments meant full understanding and acceptance of the treatment program, possible outcomes and risks involved, as well as the waiving and relinquishing of all claims the patient may have as a result of the treatments against Spinal Care Chiropractic Inc., including their officers and employees. Submission of this form signifies your consent as well agreement to the all terms and conditions mentioned in this form.
If your child is 3 years old and older, are you willing to let your child undergo the required X-Rays (and other medical tests)? All patients other than children below 5 years old and those who are pregnant are required to have a set of FULL Spine X-Ray (A-P and Lateral views) prior to treatment. If your child is aged 0-2 years old, click N/A.*
X-Ray request will be given after consultation or prior to the appointment upon request.
Signature*

Clear
Date Signed*

DayMonthYear
Date
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Spinal Care Chiropractic New Patient Intake Form

Please click all items that applies to your child.

Terms and Conditions

Overview of Chiropractic Care and Chiropractors

Fees and Termination of Treatment

Training Goals and Purpose

Recordings and Observations

Consent, Waiver, and Release