Welcome New PatientsNew Patient Form - ChildChild's NameParent's NameParent's Email*PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date Month Day YearAgeWeightGenderInsuranceInsurance CompanyInsured's NameInsured's Date of Birth Month Day YearVaccinationsHave you chosen to vaccinate your child? Yes NoIf yes, check which apply DPT MMR Chicken Pox HepatitisDescribe any or all reactionsChiropractic ExperienceDid anyone refer you to our office?Has your child been adjusted before? Yes NoIf yes, reason for adjustment.Doctor's NameApproximate date of last visitReason for VisitDescribe the reason for this visitWhat is the cause of condition?When did it begin?Has it occurred before? Yes NoIf yes, please explain.Have you seen a doctor for this condition? Yes NoDoctor's NameType of treatmentDid it help? Yes NoPregnancyDid you use any during pregnancy? drugs / medication tobacco / alcohol noDescribe deliveryAny illnesses during pregnancy, if so explain.Did you nurse? Yes NoBreastfeeding problems? Yes NoDid your baby have colic? Yes NoHealth ConditionsCheck all that apply digestive problems allergies asthma attention problems bed wetting breathing problems colic irritability skin problems vision problems constipation digestive problems ear problems frequent colds headaches hyperactivity sleeping disorders tubes in earsOther conditions not listedHas your child ever taken antibiotics? Yes NoIf yes, please explain.Child ever been hospitalized? Yes NoIf yes, please explain.Child ever had a severe fall? Yes NoChild ever involved in a car accident? Yes NoChild ever had surgery? Yes NoIf yes, please explain.Is your child accident prone? Yes NoChild taking medications? Yes NoIf yes, please explain.Does your child currently have problems interacting with others? Yes NoHave you or anyone else noticed that your child is nervous or twitches, shakes,or exhibits rocking behavior? Yes NoWhat changes in your childs behavior would you like to accomplish?I hereby authorize the doctors in this chiropractic office and whomever they may designate as their assistant to administer chiropractic care, to work with my child's condition through the use of adjustments and procedures the doctor deems appropriate. I clearly understand and agree that all services rendered are charged directly to me and that I am personally resposible for payment. The doctor will not be held responsible for any preexisting conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my child's care for any reason, any fees for professional services rendered will become due immediately. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider for services rendered.* Yes, agreeParent or Guardian Signature First Last Date MM slash DD slash YYYY
