Child Health History Form Whole Body Health

Transcription

1 Child Health History Form Whole Body Health Weymouth Road, Medina, OH Personal Information: Child s Name: Date: Child s Age: Birth Date: Sex: M F Parent(s) Name: Mother Father: Sibling s Names & Ages: Address: City: Zip Code: Home Phone: Other Number: Parent/Guardian s Family Doctor s Name: Address: Who may we thank for referring you? Has your child ever received chiropractic care? Yes No If yes, who is your child s previous Doctor of Chiropractic? The date of last visit: The reason for the last visit: Other professionals seen for this condition: Results with that treatment? Recent tests done (list date): Bloodwork Urine X-Rays Please indicate the purpose for your child s visit: Symptom Management Early Detection of Problems Prevention Improved Function Maximizing Normal Growth & Development Managing Developmental Delay(s) Other: Authorization for Care of a Minor (under 18 years old) Parent(s) Name: Telephone (best #): I hereby authorize and consent Whole Body Health to administer care as deemed necessary to my child. Parent/Guardian Signature: Date: Witness:

2 Present Health Concerns: List concern(s): When did this problem begin? Is this problem: Occasional Frequent Constant Intermittent Does the problem radiate (go anywhere)? Yes No If yes, where? What makes this worse? What makes this better? Is the problem worse during a certain time of the day? Yes No If Yes, when? Does this interfere with the child s: Sleep Eating Daily Routine Other: Often seemingly unrelated symptoms can manifest as other health concerns. Please indicate if your child has had any of the following symptoms. If none apply, please write N/A. Headaches Chest Pressure Weight Loss Dizziness Breast Pain Weight Gain Irritability Frequent Colds Dental Problems Loss of Taste Fevers Depression Sore Throat Heart Palpitations Sinus Congestion Asthma Fainting Cold Sweats Bronchitis Loss of Concentration Weakness Heartburn Pneumonia Muscle cramps Numbness in Hand(s) Fatigue Poor Coordination Ears Ringing Vision Changes Difficulty Breathing Neck Pain Upper Back Pain Low Back Pain Loss of Memory Shortness of Breath Loss of Smell Light Sensitivity Constipation Radiating Pain Allergies Diarrhea Sleeping Problems Gas/Bloating Stiffness Face Flushed Ear Pain/Infections Urinary Problems Reduced Mobility Numbness Loss of Balance Other: Birth History: Child s gestational age at birth (weeks): Duration of Birth (hours): Birth Weight: lbs oz Birth length (inches): Head circumference (cm): Was your child s birth at: Home Birthing Center Hospital Was your child born: Cephalic (head first) Breech (feet first) Were there any complications? Yes No If yes, please explain: Assistances used during delivery: Forceps Vacuum Extraction C-Section Episiotomy Was labor?: Spontaneous Induced Scheduled C-Section Emergency C-Section Were medications or epidurals given to the mother during birth? Yes No APGAR Score: At birth: / 10 After 5 minutes: / 10 Interventions immediately after birth: Vitamin K Antibiotics Silver Nitrate Hepatitis B Other:

3 Growth & Development: Was the infant alert and responsive within 12 hours of delivery? Yes No If no, please explain: At what age did the child: Respond to sound Follow an object Hold up head Vocalize Sit Alone Teethe Crawl Walk How does your child sleep? Front Back Side Do you consider the child s sleeping pattern normal? Yes No How many hours per day? If no, please explain: Family Health History: Please note any health problems (i.e.: cancer, hereditary conditions, diabetes, heart disease, etc) present in the following (if none apply please write N/A): Mother s family: Father s family: Siblings: Physical Stressors: Any traumas to the mother during pregnancy? (i.e. falls, accidents, etc.) Yes No Any evidence of birth trauma to the infant? Bruising Odd-shaped head Stuck in birth canal Cord around neck Fast or excessively long birth Respiratory depression Any falls from couches, beds, changing tables, etc? Yes No Any traumas resulting in bruises, cuts, stitches, or fractures? Yes No Any hospitalizations or surgeries? Yes No Any sports played? Is a school backpack used? Yes No Is it: Heavy? Light?

4 Chemical Stressors: Was your child breast-fed? Yes No If yes, how long? Formula introduced at what age? Which formula? Introduction of cow s milk at what age? Began solid foods at what age? Types of solid foods: Food/juice intolerance? Yes No Type: Is your child taking or have they taken any medications? (i.e. antibiotics) During the mother s pregnancy: Did the mother smoke? Yes No If yes, how much? Drink alcohol? Yes No If yes, how much? Any illnesses during the pregnancy? Yes No If yes, describe: Any supplements taken during pregnancy? Yes No If yes, describe: Any drugs taken during pregnancy? Yes No Any ultrasounds? Yes No How many? Reasons for being done: Any invasive procedures during pregnancy (i.e. amniocentesis, CVS, etc.)? Yes No Psychosocial Stressors: Any difficulties with lactation? Yes No Any problems with bonding? Yes No Any behavioral problems? Yes No Any night terrors, sleep walking, difficulty sleeping? Yes No Age of child when began daycare? Average number of hours of television per week? Do you feel that your child s social/emotional development is normal for their age? Yes No Thank you for completing this form. Please list any additional concerns below: Doctor s Notes:

5 Whole Body Health Financial Policy Most of our patients that have health or accident insurance will fall under one of the plans discussed in this policy. We ask that you read and understand our policy as it applies to your particular situation. PATIENTS WITHOUT INSURANCE We request that 100% of the first visit be paid at the time of the visit. If you prefer we can set up payments on an EFT (electronic fund transfer) from your account. We are happy to accept your check, Master Card, American Express or Visa card. GROUP OR INDIVIDUAL INSURANCE Prior to your first visit, we will call to verify benefits on your insurance. However, the benefits quoted to us by your insurance are not a guarantee of payment. A Credit Guarantee form must be filled out and signed. Payment will be due by you at the time of service for any noncovered services, deductibles or co-pays. ON THE JOB INJURY (Workman s Compensation) If you are injured on the job, your care should be paid for under your employer s Worker s Compensation insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has not been made within 3 months, or if you suspend or terminate care, any fees for services are due immediately. PERSONAL INJURY OR AUTOMOBILE ACCIDENTS Please notify your auto insurance carrier of your visit to our office immediately. Notify our insurance department immediately if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to 6 months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately. MEDICARE We do accept assignment from Medicare. You will be expected to pay for copays/coinsurance at the time of care, unless a care plan and payment arrangement are in place. Our office completes and files the forms for Medicare at no cost. SECONDARY INSURANCE Please inform us of any secondary insurance you may have. We will assist you if you need help filing. I have read and understand the payment policy of Whole Body Health (WBH). I understand that my insurance is an arrangement between myself and my insurance company, NOT between WBH and my insurance company. I request that WBH prepare the customary forms at no charge so that I may obtain insurance benefits. Patient signature (or guardian if patient is a minor) Date

6 Whole Body Health Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we begin any health care treatment we require you to read and sign this consent form stating that you understand and agree with how your records will be used. 1. The patient understands and agrees to allow this medical office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations and coordination of care. This includes, but is not limited to: your insurance provider, referring physicians and contacts you designate, and for law enforcement and court order mandates (in conjunction with Office of Civil Rights mandates). 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. 3. A patient s written consent need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of the records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented. 5. For your security and right to privacy, all staff has been trained in the area of patient privacy. A privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care treatments, the practitioner has the right to refuse to give care. My Patient Health Information can be shared in the following ways (initial all that apply): Message can be left: at home, on cell, at work, with another person (please list all that apply: ) Information can be sent via: mail I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. Name of Patient Date Signature

7 Whole Body Health Consent/Permission to Treat Form I hereby request and consent to physical medicine and nutrition treatments including but not limited to structural manipulation, various muscle and neurological testing, physical therapy, allergy elimination, nutritional advice, detoxification, injections, various tests and other procedures, including various modes of physical therapy on me (or on the patient named below, for whom I am legally responsible) by one the doctors of Whole Body Health and including those personnel working at Whole Body Health or any other office or clinic, whether signatories to this form or not. I understand that I will be given the opportunity to discuss with the doctor and/or with other office or clinic personnel the nature and purpose of all chiropractic treatments and procedures before they are performed to me or asked of me. I understand that results are not guaranteed. I understand and am informed that, as in the practice of standard medicine, in the practice of physical medicine there are some risks to treatment, including, but not limited to pain, an increase in symptoms or no improvement at all. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. I for myself and my personal representatives, heirs, next of kin, hereby release, waive, discharge and covenant not to sue Whole Body Health, its officers and members, owners and employees from all liability to myself, my personal representatives, assigns, heirs and next of kin for all loss or damage, or any claim or damage therefore, on account of injury of any kind due to the negligence of the Backbone of Health, its officers and members, owners and employees. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I have discussed and understand other treatment options that may be available to me through standard medical approaches and/or other health care providers. Whole Body Health does not offer to diagnose or treat any disease or condition found in the body. We are not here to replace your primary care physician. However, if during the course of an examination, we encounter 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 that specializes in that area. We may give you information or advice about your present prescriptions, we are in no way recommending you to change or go off of any of your medicine, please advise your primary care physician before making any changes. Regardless of what the disease is called, we do not offer to treat it. You may be recommended nutrition; this nutrition is not meant to cure or treat any disease but rather to help bring about a state of balance in the body. We do not offer advice regarding treatment prescribed by others. Our only practice objective is to bring balance to the body s systems so that your body may better able to heal itself. Parent/Guardian Name (Printed): Patient (Child) Name (Printed): Relationship to Patient/Child: Signature of Parent/Guardian: Date:

8 Privacy Policy Acknowledgement Form I acknowledge that I have reviewed/received a copy of Whole Body Health LLC s Notice of Privacy Practices. Name of Patient (Please Print) Signature of Patient Date OR Signature of Personal Representative Authority of Personal Representative to Sign for Patient (check one) o Parent o Guardian o Power of Attorney o Other: Please note: It is your right to refuse to sign this Acknowledgement Office Use Only I tried to obtain written acknowledgement by the individual noted above of the receipt of our Notice of Privacy Practices, but it could not be obtained because: An emergency prevented us from obtaining acknowledgement. A communication barrier prevented us from obtaining acknowledgment. The individual was unwilling to sign. Other: Staff Member Signature Date