NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT MAILING DOCTOR S NAME: PLEASE EXPLAIN: DOCTOR S NAME: RESULTS:

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1 ABOUT THE CHILD CHIROPRACTIC EXPERIENCE NAME: WHO REFERRED YOU TO OUR OFFICE? ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: HOW DID YOU HEAR ABOUT OUR OFFICE (ALL THAT APPLY): NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT MAILING HAVE YOU BEEN ADJUSTED BY A CHIROPRACTOR BEFORE? IF YES, WHAT WAS THE REASON FOR THE VISITS? DATE OF BIRTH: SOCIAL SECURITY NUMBER: GENDER: PARENT NAME: ADDRESS: SAME AS ABOVE CITY: HOME PHONE: ADDRESS: AGE: WEIGHT: ABOUT THE PARENT STATE/ZIP CODE: CELL PHONE: DOCTOR S NAME: APPROXIMATE DATE OF LAST VISIT: HAS ANY ADULT IN YOUR FAMILY EVER SEEN A CHIROPRACTOR? HAS ANY OTHER CHILD IN YOUR FAMILY EVER SEEN A CHIROPRACTOR? REASON FOR THIS VISIT DESCRIBE THE REASON FOR THIS VISIT: IS THE PURPOSE OF THIS APPOINTMENT RELATED TO: SPORTS AUTO FALL HOME INJURY OTHER EMPLOYER NAME: WHEN DID THIS CONDITION BEGIN? EMPLOYER ADDRESS: EMPLOYER CITY: WORK PHONE: EMPLOYER STATE/ZIP CODE: POSITION TITLE: HAS THIS: GOTTEN WORSE STAYED CONSTANT COME AND GONE DOES THIS INTERFERE WITH: SLEEP DAILY ROUTINE OTHER ACTIVITIES EMERGENCY CONTACT: RELATIONSHIP: PHONE: HAS THIS OCCURRED BEFORE? HAVE YOU SEEN OTHER DOCTORS FOR THIS CONDITION? VACCINATIONS HAVE YOU CHOSEN TO VACCINATE YOUR CHILD? IF YES, CHECK ALL THAT YOUR CHILD HAS RECEIVED: DPT MMR CHICKEN POX HEPATITIS OTHER WERE YOU TOLD THAT YOU HAD A CHOICE IN VACCINATING? Y N WOULD YOU LIKE INFORMATION ON THE OTHER SIDE OF THIS ISSUE? Y N DOCTOR S NAME: TYPE OF TREATMENT: RESULTS: DESCRIBE ANY AND ALL REACTIONS TO VACCINE (S):

2 DURING PREGNANCY DID YOU USE: DRUGS/MEDICATIONS IF YES, PRENATAL HISTORY TOBACCO/ALCOHOL CHILD S CURRENT HEALTH HAS YOUR CHILD EVER TAKEN ANTIBIOTICS? LOCATION OF BIRTH: HOME BIRTHING CENTER HOSPITAL HAS YOUR CHILD EVER BEEN HOSPITALIZED? DESCRIBE YOUR DELIVERY: LABOR WAS CHEMICALLY INDUCED C-SECTION DELIVERY DOCTOR PULLED OR TWISTED BABY LABOR WAS DOCTOR ASSISTED FORCEPS/VACUUM EXTRACTION PREMATURE DELIVERY THE NATIONAL SAFETY COUNCIL REPORTS APPROXIMATELY 50% OF CHILDREN FALL HEAD FIRST FROM A HIGH PLACE DURING THEIR FIRST YEAR OF LIFE (I.E.: BED, CHANGING TABLE, STAIRS, ETC.). WAS THIS THE CASE FOR YOUR CHILD? HOW LONG WAS THE LABOR FROM THE FIRST REGULAR CONTRACTIONS TO THE BIRTH? HOW LONG WAS THE 2ND STAGE (THE PUSHING PHASE) OF LABOR? HAS YOUR CHILD EVER BEEN IN A CAR ACCIDENT? DESCRIBE ANY COMPLICATIONS EXPERIENCED DURING DELIVERY: HAS YOUR CHILD EVER HAD SURGERY? DID YOU EXPERIENCE ANY ILLNESS(S) WHILE PREGNANT? PLEASE DESCRIBE ANY GENETIC DISORDERS AND/OR DISABILITIES: DOES YOUR CHILD HAVE DIFFICULTY INTERACTING WITH OTHERS? HAVE YOU OR ANYONE ELSE NOTICED THAT YOUR CHILD IS NERVOUS, TWITCHES, SHAKES OR EXHIBITS ROCKING BEHAVIOR? BIRTH WEIGHT: BIRTH LENGTH: APGAR SCORES: AT 1 MIN /10 AT 5 MIN /10 DOES YOUR CHILD EVER BANG HIS/HER HEAD REPEATEDLY AGAINST A WALL, BED, OR OTHER OBJECT? ULTRASOUND DURING PREGNANCY? NUMBER: DID YOU BREASTFEED YOUR BABY? IF YES, HOW LONG? HAS YOUR CHILD BEEN INVOLVED IN ANY HIGH IMPACT/CONTACT TYPE SPORTS (I.E.: SOCCER, FOOTBALL, MARTIAL ARTS, GYMNASTICS, ETC.) DID YOU FORMULA FEED YOUR BABY? IF YES, HOW LONG? PLEASE LIST: AT WHAT AGE DID YOU INTRODUCE: SOLIDS: COW S MILK: WHAT CHANGES (IF ANY) IN YOUR CHILD S HEALTH OR BEHAVIOR WOULD YOU LIKE ACCOMPLISHED? ARE YOU AWARE OF ANY FOOD OR JUICE ALLERGIES OR INTOLERANCES?

3 COMPLETE THE HEALTH HISTORY APPLICABLE TO YOUR CHILDS AGE AGES 0-3 HEALTH HISTORY 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 appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care. ACID REFLUX CONSTIPATION FREQUENT COLDS, COUGHS, DO YOU HAVE ANY CONCERNS ABOUT YOUR CHILD S DIET? DOES YOUR CHILD HAVE FOOD ALLERGIES? NUTRITION ASTHMA DIARRHEA HYPERACTIVITY BED WETTING DIFFICULT WEIGHT GAIN LEARNING DISORDERS COLIC EAR INFECTIONS SLEEPING DIFFICULTIES AGES 4-8 HEALTH HISTORY 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 appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted DOES YOUR CHILD HAVE PERSISTENT OR INTERMITTENTLY OCCURRING SKIN RASHES? DOES YOUR CHILD TAKE VITAMIN SUPPLEMENTS? WHICH SUPPLEMENTS & BRAND? ANXIETY DIARRHEA NERVOUSNESS ASTHMA EAR INFECTIONS PAIN BED WETTING HEADACHES SORE THROAT BRONCHITIS HYPERACTIVITY UPSET STOMACH DOES YOUR CHILD ELIMINATE STOOLS EACH DAY? WHAT DOES YOUR CHILD USUALLY EAT FOR BREAKFAST? CONSTIPATION LEARNING DISORDERS URINARY INFECTIONS AGES 9-13 HEALTH HISTORY INSTRUCTIONS: Please check each of the conditions that the child now or has had in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care. ANXIETY DEPRESSION LEARNING DISORDERS ASTHMA DIFFICULTY/PAINFUL/ IRREGULAR PERIODS NECK STIFFNESS/PAIN BACK PAIN/STIFFNESS HEADACHES SHOULDERS/ELBOW, WRIST PAIN WHAT DOES YOUR CHILD USUALLY EAT FOR LUNCH? WHAT DOES YOUR CHILD USUALLY EAT FOR DINNER? WHAT DOES YOUR CHILD USUALLY EAT FOR SNACKS? HOW MUCH COW S MILK DOES YOUR CHILD DRINK EACH DAY? CONSTIPATION HIPS, KNEES, ANKLES STRESS DIARRHEA HYPERACTIVITY URINARY INFECTIONS AUTHORIZATION FOR CARE OF A MINOR I understand that all services are to be paid in full at the time of service, unless other arrangements have been made and agreed in writing. I hereby authorize the doctors in this chiropractic office and whomever they may designate as their assistant to administer chiropractic care in order to work with my body 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 responsible for payment. I agree that I am responsible for all bills incurred at this office. The doctor 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 care for any reason, any fees for professional services rendered me will become immediately due and payable. PARENT OR GUARDIAN AUTHORIZING CARE SIGNATURE: DATE:

4 Notice of Health Care Authorization & Privacy Policy I have been offered but have not made a request to review a copy of the Notice of Privacy Practices for Protected Health Information. The Notice of Privacy Practices describes the types of uses and disclosures of my Protected Health Information (PHI) that will occur in my care, payment of my bills or in the performance of health care operations of this Chiropractic office. This Notice of Privacy Practices also describes the rights and duties of the Chiropractor with respect to my protected health information. I hereby give permission to use and/or disclose Protected Health Information in accordance with the following: - I give permission to to conduct, plan and direct my care and follow up with multiple healthcare providers who may be involved in that care. - I give permission to use my physical address, address, phone number, and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, newsletters, information about health care or other health related information. - If contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail. - I give permission to to obtain payment from third party payers, if applicable. - I give permission to to use my name and photograph on their welcome board, referral board, bulletin board and other informational material such as their brochure, website, social media sites and articles in print media. - I give permission to to use any testimonial written by me for informational purposes such as sharing with other clients or prospective clients, in their brochure, on their website, or in ads in print media. - I give permission to adjust me in an open room where others are also being adjusted. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the Chiropractor at any time in private, the Chiropractor will provide a room for these conversations. 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 of a request. You may request to view changes to your records. By signing this form you are giving permission to use and disclose your Protected Health Information in accordance with the directives listed above. The use of this format is intended to make your experience at more efficient and productive as well as to enhance your access to quality of Chiropractic Care and health information. This authorization will remain in effect for the duration of my care at plus 7 years unless revoked by me. I also understand that I can request, in writing, that you restrict how my personal information is used and/or disclosed. I have read and understand this Healthcare Authorization Form. My signature below represents agreement with these practices. Name of Parent or Guardian (Print) Signature Date / /

5 Our Fee Structure Please note our fees for your initial visit: Consultation, exam and nervous system scan: $59 - $144 depending on severity of the case X-rays, if applicable: Fee paid to radiology provider Please note that if you have been involved in a motor vehicle accident, our fee structure may differ due to the complexity of your needs in such cases. Also, note that your clinical Report of Findings, the time that your doctor will spend with you to go over your results, will be complimentary. I have completely read and understood the above statement concerning fees and choose to receive care. Signature Date / / Financial Policy Recommendations for care are based on necessity and not insurance benefits. Please understand that insurance companies pay for sick-care, not wellness care as provided by. On occasion your insurance benefits may contribute to the cost of your care here at. Your insurance policy is between you and your insurance company, not between your insurance company and us. We are happy to provide you with a printed claim from, upon request, that you may choose to send to your insurance company. You understand that we do not guarantee that your insurance company will pay for treatments rendered in this clinic and understanding that the cost for service rendered to you by is your personal responsibility. * Please note that is a non-payable provider with Blue Cross Blue Shield. I CLEARLY UNDERSTAND AND AGREE that I am responsible for all bills incurred at this office relating to my care. I also understand that I may suspend or terminate my care, all fees for professional services rendered me will become immediately due and payable. I agree that if I fail to provide with payments made in my name for services rendered at Healing Touch, I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider for services rendered. I have completely read and understood the above statement concerning insurance and choose to receive care. Signature Date / /

6 Patient Birth Records Release I,, Parent (or legal guardian) of the below mentioned child, hereby authorize and direct to release the records relating to the birth (Newborn Admission Profile), including the APGAR score of, to Healing Touch Chiropractic. Date of Birth: May this signed consent form be your good authority to do so. Parent/Guardian Signature: Date: Witness: Fax Records to or mail to: st Ave E, Unit D, ~