CHILD SPINAL HEALTH FORM
Please complete the following information:
Patient's Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
*
Birthdate
*
-
Month
-
Day
Year
Date
Social Security Number
*
Parent's Name
*
First Name
Last Name
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Where would you prefer to be contacted?
*
Home Phone
Cell Phone
In case of emergency, contact:
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Family Medical Doctor
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Family Dentist
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Previous Chiropractor (If none, write N/A)
*
I will be paying by:
*
Cash
Check
Visa
Mastercard
Back
Next
Do you experience any of these health problems?
*
headaches
stressed shoulders
neck pain
lower back pain
pulled muscles
leg and hip pain
stiffness
mid-back pain
car accident
scoliosis
numbness
loss of energy
sinus pain/allergies
emotional stress
bed wetting
earaches
sleeping problems
wrist or joint pain
stomach/digestive trouble
frequent colds/flus
None
Current health problems (if none, write N/A)
*
Currently taking medications (if none, write N/A)
*
Mark any problem areas
*
Do these conditions interrupt?
*
Family Life
School
Ability to exercise
Sleeping Pattern
Social Life
None
What methods have you tested?
*
Exercise
Physical Therapy
Massage
Prescription Drugs
Nothing
Check all of the true statements:
*
Previous methods were ineffective
Your condition will not improve by itself
The Nervous System controls the function of all your muscles and organs
None
How long have you been living this way?
*
Weeks
Months
Years
Would you like to find the cause of your problems?
*
Yes
No
Maybe
What results do you want for yourself?
*
Reduce Pain
Restore Health
Maintain Health
Back
Next
I understand and agree that health insurance is an agreement between the carrier and myself. I understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment.
*
Date
*
-
Month
-
Day
Year
Date
I authorize 1st Place Chiropractic to release any information or records necessary to process insurance forms.
*
Date
*
-
Month
-
Day
Year
Date
Signature of Parent/Guardian
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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