• ABOUT THE PATIENT

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • REASON FOR THIS VISIT

  • Which best describes your reason for consulting our office?
  • Since the problems began, is it:
  • What is the pattern of this problem?
  • Does this interfere with your child's sleep?
  • Does this interfere with your child's eating habits?

  • The human body is designed to express health and function normally. However, events may occur in life, which can interfere with this natural ability. This interference is most commonly the result of vertebral subluxations. Subluxations may be caused by physical, chemical, or emotional stress. The practice of chiropractic is based on locating and reducing nerve system interference caused by vertebral subluxations.

  • HEALTH HISTORY

  • Have you or your child been adjusted by a chiropractor before?
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  • Number of doses of antibiotics your child has taken:

  • Number of doses of other prescription medications your child has taken:

  • Has your child ever been hospitalized, had any surgeries or major illnesses?
  • Have you withheld any vaccines?
  • Please check any of the following conditions that your child has now or had previously. While they may seem unrelated to the purpose of this appointment, they can affect the overall diagnosis and care plan.

  • PSYCHOSOCIAL STRESSES

  • Are / were there any difficulties with lactation?
  • Are / were there any problems with bonding?
  • Are there any behavioral problems?
  • Is there any inattention?
  • Hyperactivity / restlessness?
  • Compulsiveness?
  • Are there any difficulties at daycare or school?
  • Are there any challenges with learning deficiencies?
  • Are there any night terrors, sleep walking or difficulty sleeping?
  • Are there any prolonged temper tantrums or separation anxiety?
  • Is the child in daycare?
  • Is there a nanny or regular sitter during the day?
  • Is the child home-schooled?
  • Do you feel that your child's social and emotional development is normal for their age?

  • AUTHORIZATION FOR CARE OF MINOR

  • In order for the health professional as indicated below to make a determination on the suitability of my child’s/guardian’s case for care, I acknowledge and understand that a thorough evaluation must be completed. I do hereby request and consent to the performance of such an evaluation by the person(s) named below, or any party authorized to do so by that person.

    I have had the opportunity to discuss with the Doctor of Chiropractic indicated below, or with any party authorized to do so by that chiropractor, about the nature and purpose of the examination process. I understand that there may be remotely associated risks with examinations, as there are with any and all healthcare treatments. In healthcare, the matter of whether any treatment is appropriate or not is determined by looking at the level of risk and comparing this with the level of expected benefit.I understand that I may ask the doctor to stop the examination at any time. I also understand that by signing this form, the chiropractor continues to be obligated for best practices delivered in the child’s interests.

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