Intake Form: 6-17 Years

PEDIATRIC NEW PATIENT INFORMATION

6-17 Years Old
Child and Family Chiropractic Center
Date

MonthDayYear
Date
PATIENT INFORMATION

6-17 Years
Child's Name
Child's Nickname
Reason for visit
Child's Sex
Date of Birth

MonthDayYear
Date
Child's Age
Child's Home Phone #
Child's Home Address
Who may we thank for referring you?
FAMILY INFORMATION

6-17 Years
Mother's name
Partner's name
Mother's Home phone #
Partner's Home phone #
Mother's Work phone #
Partner's Work phone #
Email
example@example.com
Monthly StatementsNewslettersOther
MarriedSingleDivorcedWidowed
List Ages of Other Children in Family
Predominant language used at home
PAYMENT INFORMATION

6-17 Years
YesNoUnsure
If you have insurance that may cover chiropractic services, please provide the following information relating to the person who is responsible for the child's health insurance coverage.
Policy Holder's Name
Policy Holder's Birth Date

MonthDayYear
Date
Insurance Company Name
Patient's ID #
Policy Holder's Employer
Group #
Insurance Card

Cancelof
CONSENT TO TREAT

6-17 Years
Being the parent or legal guardian of this child, I hereby authorize this office and its doctors to examine and administer care to my son/daughter namedas the examining / treating doctor deems necessary. I understand and agree that I am personally responsible for payment of all fees charged by this office for such care.
Parent's Name
Signature

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Date

MonthDayYear
Date
Witnessed by
Child and Family Chiropractic Center 8120 Penn Ave. S., Suite 245 Bloomington, MN 55431 (612)590-5881 Revised 07/20
SCHOOL-AGED CHILD HISTORY

6-17 YEARS OLD
Today's Date

MonthDayYear
Date
Child's Name
MaleFemale
Date of Birth

MonthDayYear
Date
Age
Reason for today's visit?
When did this problem first occur?
Has your child ever had this problem before?
Has your child previously been treated for this problem?
Doctor's Name
Has your child previously had chiropractic care?
When?
HEALTH HISTORY

6-17 Years
The following questions are designed to help the doctor provide a detailed evaluation of your child.
Back or neck painPain in the arms or legsHeadachesAsthmaAllergiesEaraches
Has your child ever fallen from a bike, skateboard, scooter, rollerblades or similar?
Has your child ever had a problem with bed-wetting?
Has your child ever been in a motor vehicle collision or near miss?
Has your child ever had any broken bones?
Please list any surgeries your child has had:
At present, is your child taking any medications?
Does your child have any other health conditions or concerns?
LIFE STYLE

6-17 Years
What grade is the child in?
How heavy is the child's book bag or backpack?
What sports does the child participate in?
What are the child's hobbies?
How many hours (per day) does the child watch tv?
How many hours (per day) does the child use a computer?
How many hours (per day) does the child play video games?
On average, how many hours per night does the child sleep?
Are there any smokers in the child's home?
Does the child report or complain of feeling "stressed out"?
Does the child have any difficulties or issues reading the board in class?
Does the child wear glasses or contacts?
Does reading cause headaches for the child?
NUTRITION

6-17 Years
What does the child typically eat for breakfast?
What does the child typically eat for lunch?
What does the child typically eat for dinner?
What does the child typically eat for snacks?
What are some favorite foods?
Approximately how much water does this child consume each day?
How often does this child consume sodas?
How often does this child eat fast food ?
PATIENT CONSENT FORM

6-17 Years
Patient Name
Date of Birth

MonthDayYear
Date
I, the patient above, or guardian for the patient, voluntarily consent to such care encompassing diagnostic procedures and medical treatment provided by the chiropractic physician as is necessary in his/her professional judgment. I understand that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as the result of examination or treatment in this facility.

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I hereby authorize Child and Family Chiropractic Center to release medical information regarding myself and my current condition to my insurance company for purposes of payment and / or quality reviews; and to referring, consulting, treating physicians or other medical providers as necessary to support continuation of care.

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I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

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I understand and agree to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. I understand that if I want a more detailed account of how my Patient Health Information is going to be used in this office and my rights concerning those records, I can request and obtain a copy of the HIPAA NOTICE that is available at the front desk. I understand that if there is anyone that I do not want to receive my medical records, I will inform the office.

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I have read this form and understand its contents at this date and time.
PATIENT OR LEGAL REPRESENTATIVE
LEGAL RELATIONSHIP
DATE

MonthDayYear
Date
Should be Empty:

PEDIATRIC NEW PATIENT INFORMATION

PATIENT INFORMATION

FAMILY INFORMATION

PAYMENT INFORMATION

CONSENT TO TREAT

SCHOOL-AGED CHILD HISTORY

HEALTH HISTORY

LIFE STYLE

NUTRITION

PATIENT CONSENT FORM