Child Form About The Child Child Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Date of Birth * MM DD YYYY Age * Gender Male Female About The Parent Parent Name * First Name Last Name Address Only if different than child's address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Cell Phone (###) ### #### Email Address * Employer Name * Employer City * Employer State/Zip Code * Work Phone Number (###) ### #### Position Title Vaccinations Have you chosen to vaccinate your child? * Yes No If yes, check all that your child has received: * DPT MMR Chicken Pox Hepatitis Other Chiropractic Experience Who referred you to our office? Have you seen or heard of our office because of: * Check all that apply. Newspaper Sign Internet search (i.e. Google) Community Event Mailing Social Media Have you been adjusted by a chiropractor previously? * Yes No If yes, what was the reason for those visits? Doctor's Name Approximate Date of last visit MM DD YYYY Has any adult in your family seen a chiropractor? * Yes No Has any child in your family seen a chiropractor? * Yes No Reason for this visit Describe the reason for this visit: * Is the purpose of this appointment related to: * Sports Auto Fall Home Injury Other Please explain When did this condition begin? Has this condition: Gotten worse Stayed constant Come and gone Does this condition interfere with: Sleep Daily Routine Other Activities Has this condition occurred before? Yes No Please explain Have you seen other doctors for this condition? Yes No Doctor's Name Type of treatment Results Mother's Pregnancy & Labor During pregnancy did you use: Drugs/Medication Tobacco/Alcohol If yes, please explain Describe your deliver Labor was chemically induced Labor was doctor assisted C-section delivery Forceps/vacuum extraction Doctor pulled or twisted baby Premature deliver Please explain Did you experience any illness while pregnant? Yes No Please explain Did you nurse the baby? Yes No Did you experience feeding problems? Yes No Did your baby have colic? Yes No Vaccinations? Yes No Child's Health History Please check all that apply: * INSTRUCTIONS: Please check each of the diseases or conditions that the child now or has had in the past. While they may seem unrelated to the purpose of the appointments, they can affect the overall diagnosis, care plan, and the possibility of being accepted for care. Allergies Constipation Irritability Asthma Digestive Problems Skin Problems Attention Problems Ear Problems Sleeping Disorders Bed Wetting Frequent Colds Tubes in the ears Breathing problems Headaches Vision problems Colic Hyperactivity Other Has your child ever taken antibiotics? * Yes No Has your child ever been hospitalized * Yes No Has your child ever had a severe fall? * Yes No Has your child ever been in a car accident? Yes No Is your child accident prone? Yes No Has your child ever had surgery? * Yes No Is your child currently taking medications? * Yes No Does your child have difficulty interacting with others? * Yes No Have you or anyone else noticed that your child is nervous, twitches, shakes, or exhibits rocking behavior? * Yes No If you answered yes to any of the above questions, please explain: What changes (if any) in your child's health or behavior would you like accomplished? Chiropractic Awareness Doctors of chiropractic work with the nervous system? Yes No The nervous system controls all bodily functions and systems? Yes No Chiropractic is the largest natural healing profession in the world? Yes No If chiropractic care starts at birth, you can achieve a higher level of health throughout life? Yes No Authorization of Care I hereby authorize the doctors in this chiropractic office and whomever they may designate as their assistant to administer chiropractic care to my child through the use of adjustments and procedures the doctor deems appropriate. I clearly understand and agree that all services rendered to my child are charged directly to me and that I am personally responsible for payment. I agree that I am responsible for all bills incurred at this office. Dr. DeVries will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand if I suspend or terminate my child’s care for any reason, any fees for professional services rendered will become immediately due and payable. I hereby authorize assignment of my child’s insurance rights and benefits (if applicable) directly to the provider for services rendered. I authorize the use of this signature to allow the insurance companies to pay TrueNorth Chiropractic, PA directly any amounts payable as my child’s assignment of benefits. I authorize the use of this signature on any insurance submissions. I have read and agree to the above authorization of care * Yes Name of Child First Name Last Name Birthdate * MM DD YYYY Parent or guardian authorizing care signature: * Type your full legal name to digital sign this document. Today's Date * MM DD YYYY Notice of Privacy Policy Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment or practice operations will be made only after obtaining your consent. • You may request restrictions on your disclosures. •You may inspect and receive copies of your records within 30 days with a request. • You may request to view changes to your records. • In the future, we may contact you for appointment reminders, announcements and to inform you about our practice and its staff. Statement of understanding * I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: • Conduct, plan and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly. • Obtain payment from third party payers. • Conduct normal healthcare operations such as quality assessments and physician’s certifications. I Understand Agree to Notice * I have read and understand the Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and or disclosed. Yes Terms of Acceptance When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is only when the patient understands both the objective and the method that they will be able to attain it. This will prevent any confusion or disappointment. Adjustment * An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments to the spine. I understand Health * Health is a state of optimal physical, mental and social well being, not merely the absence of disease. I understand Vertebral Subluxation * Vertebral Subluxation is a misalignment of one or more of the joints of the body. This can cause pain or alteration of nerve function and interference of the transmission of nerve impulses, lessening the body’s innate ability to maintain maximum health. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our ONLY practice objective is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxation. I have read and fully understand the above statement. Any questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. Signature * By typing your name you are digitally signing this form. Witness * By typing your name you are digitally signing this document. Today's Date * MM DD YYYY Thank you!
