Intake Form: 0-2 Months

PEDIATRIC NEW PATIENT INFORMATION

0-2 Months Old
Child and Family Chiropractic Center
Date

MonthDayYear
Date
PATIENT INFORMATION

0-2 Months
Child's Name
Child's Nickname
Reason for visit
Child's Sex
Date of Birth

MonthDayYear
Date
Child's Age
Child's Home Phone #
Format: (000) 000-0000.
Child's Home Address
Who may we thank for referring you?
FAMILY INFORMATION

0-2 Months
Mother's name
Partner's name
Mother's Home phone #
Format: (000) 000-0000.
Partner's Home phone #
Format: (000) 000-0000.
Mother's Work phone #
Format: (000) 000-0000.
Partner's Work phone #
Format: (000) 000-0000.
Email
example@example.com
Monthly StatementsNewslettersOther
MarriedSingleDivorcedWidowed
List Ages of Other Children in Family
Predominant language used at home
PAYMENT INFORMATION

0-2 Months
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

0-2 Months
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
PREGNANCY HISTORY

0-2 Months
Today's Date

MonthDayYear
Date
Child's Name
MaleFemale
Date of Birth

MonthDayYear
Date
Age
Mother's Name
How many children do you have?
What was the term of your pregnancy (in weeks)?
Fall/sMotor Vehicle AccidentNear miss MVAHigh Blood PressureDiabetesAnemiaMorning SicknessIndegestionSeizuresSwollen AnklesThyroid ProblemsHeart ProblemsHospitalizationOther
TobaccoAlcoholNon-prescribed drugsPrescribed drugsOver-the-counter meds
If you answered YES to any of the above, please describe:
BIRTH HISTORY

0-2 Months
How long was the labor from the first regular contraction to the birth?
How long was the 2nd stage (the pushing phase) of the labor?
Hospital BirthHome BirthMidwife AssistedVaginal DeliveryPlanned C-SectionEmergency C-SectionPitocin InducedForceps DeliveryVacuum ExtractionAnesthesia AdministeredFetal DistressMeconium StainingHead PresentationBreech Presentation
BABY'S CONDITION IMMEDIATELY AFTER BIRTH:
Apgar Scores at 1 minute (out of 10):
Apgar Scores at 5 minutes (out of 10):
Baby Cried Immediately After Birth Cried Strongly Blue face Pink all over
StrongWeakDid not cry
If baby did not cry, for how long?
PinkBlue FaceBlue Hands and Feet
Arms and Legs Actively MovingFloppyBlue Hands and FeetOther
What intensive care required?
If So, Number of Days in Neonatal Intensive Care Unit
Medication given at birth?
Vaccines administered?
Birth Weight lbs/kgs
Birth Length
Baby Went Home on Day
INFANT HISTORY

0-2 Months
Today's Date

MonthDayYear
Date
Patient's Name
MaleFemale
Date of Birth

MonthDayYear
Date
Age
The following questions are designed to help the doctor provide a detailed evaluation of your child.
How many hours does your child sleep between feeds?
How about during the day?
How about during the night?
Does your baby go to sleep easily? Please describe.
Does baby have a preferred sleeping position?
Does baby cry if you change this sleeping position?
Does baby have any feeding difficulties?
Is baby being breastfed? If NO, how long was baby breastfed (wks/months)?
Does baby have one-sided feeding preference? If so, which is the preferred breast/side?
Is baby formula fed? If so, which formula or other milk source?
Does baby frequently spit-up after feeding?
Does baby cry a lot?
How many hours does baby cry each day?
Does baby pass a lot of intestinal gas?
Does baby have a preferred head position?
Does baby frequently arch their head and neck backwards?
Does baby cry or become irritable during diaper changes?
Has baby ever had a fever?
TRAUMA

0-2 Months
Has your child had any recent falls or trauma?
Describe the trauma and the date it occurred?

MonthDayYear
Date
Has your child ever fallen down stairs or fallen from any height?
Has your child ever been in a motor vehicle collision or near miss?
Has your child ever had a bone fracture or joint dislocation?
Has your child had any other trauma or injuries?
HEALTH HISTORY

0-2 Months
Is your child presently receiving any medications?
Has your child ever been to the hospital or ER for evaluation or treatment?
Has baby been vaccinated?
Has your child been recently vaccinated?
PATIENT CONSENT FORM

0-2 Months
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
Type a question
Should be Empty: