Child Health Record Form

CHILD HEALTH RECORD

Application for Care

GENDER:*
Please select one option

SUPPLEMENTS AND MEDICATIONS

DOES YOUR CHILD HAVE ANY MEDICATION ALLERGIES? IF YES WHAT MEDICATION AND REACTION:

CHIROPRACTIC EXPERIENCE

HOW HAVE YOU SEEN OR HEARD OF OUR OFFICE (✓ ALL THAT APPLY)

HISTORY OF COMPLAINT

Purpose of this visit:*
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When:
EVER HAD THIS PROBLEM BEFORE:
ANY BOWEL OR BLADDER PROBLEMS SINCE THIS PROBLEM BEGAN:
HAS YOUR CHILD SEEN ANY OTHER DOCTORS FOR THIS PROBLEM:
HOW IS THIS PROBLEM NOW:
HAS YOUR CHILD EVER BEEN INJURED PLAYING ORGANIZED SPORTS:
HAS YOUR CHILD EVER BEEN INJURED IN AN AUTO ACCIDENT:

PAST HISTORY

HAS YOUR CHILD EVER SUFFERED FROM: (CHECK ALL THAT APPLY)

FAMILY HISTORY

DOES ANYONE IN YOUR FAMIY SUFFER WITH THE SAME CONDITION(S)?
IF YES WHOM:
HAVE THEY EVER BEEN TREATED FOR THEIR CONDITION?
ANY OTHER HEREDITARY CONDITIONS THE DOCTOR SHOULD BE AWARE OF?

INFORMED CONSENT

I UNDERSTAND THAT I AM DIRECTLY AND FULLY RESPONSIBLE TO HEALTHY CHOICE FAMILY CHIROPRACTIC FOR ALL FEES ASSOCIATED WITH CHIROPRACTIC CARE MY CHILD RECEIVES.

THE RISKS ASSOCIATED WITH EXPOSURE TO IONIZATION AND SPINAL ADJUSTMENTS HAVE BEEN EXPLAINED TO ME TO MY COMPLETE SATISFACTION, AND I HAVE CONVEYED MY UNDERSTANDING OF THESE RISKS TO THE DOCTOR. AFTER CAREFUL CONSIDERATION I DO HEREBY REQUEST AND AUTHORIZE IMAGING STUDIES AND CHIROPRACTIC ADJUSTMENTS FOR THE BENEFIT OF MY MINOR CHILD FOR WHOM I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES ON BEHALF OF.

Consent*
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MEDICAL INFORMATION RELEASE FORM (HIPAA)

RELEASE OF INFORMATION:*
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Thank you for taking the time to fill out this form.

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Office Hours

Closed Daily for Lunch from 11:30 am - 1:30 pm

Monday

8:00 am - 6:30 pm

Tuesday

1:30 pm - 5:30 pm

Wednesday

8:00 am - 6:30 pm

Thursday

7:30 am - 6:00 pm

Friday

Closed

Saturday

Closed

Sunday

Closed

Monday
8:00 am - 6:30 pm
Tuesday
1:30 pm - 5:30 pm
Wednesday
8:00 am - 6:30 pm
Thursday
7:30 am - 6:00 pm
Friday
Closed
Saturday
Closed
Sunday
Closed