New Patient Questionnaire- Child (12 or Younger)

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Patient Information

Name*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Cell Phone:*

Cellular/Mobile Provider:*

Home Phone:

Email:

Enter Email Confirm Email

Date of Birth:*

YYYY

Gender:*

Male

Female

Mother's Name:

First Last

Mother's Occupation:

Mother's Phone:

Mother's Email:

Enter Email Confirm Email

Father's Name:

First Last

Father's Occupation:

Father's Phone:

Father's Email:

Enter Email Confirm Email

Emergency Contact Information:

Name of Emergency Contact:

First Last

Relationship:

Emergency Contact Phone Number:

How were you referred to our practice?

Physcian Referral

Friend/Relative

Facebook Ad

Internet Search

Reputation/Word of Mouth

Sign

Wellness Presentation

Website

Other

Female Only

The first day of your last period (menstrual cycle):*

Month

Day

Year

If this questions does not apply to you, please enter 01 01 1930.

How Can We Help Your Child?

Wellness Check-Up

Symptom-Related Check-Up

If your child is already experiencing a symptom, please describe it:

Has your child ever suffered from any of the following? Check All That Apply:

Allergies

Anemia

Arm Problems

Asperger Syndrome

Asthma

Attention Deficit Hyperactivity Disorder (ADD/ADHD)

Autism

Back Aches

Bed Wetting

Behavioral Problems

Broken Bones

Colic

Concussion(s)

Convulsions/Seizures

Delayed Speech

Diabetes Type 1

Diabetes Type 2

Digestive Issues (Constipation/Diarrhea)

Dizziness

Ear Infections

Fainting

Frequent Colds/Flu

Headaches

Heart Trouble

Hyperactivity

Hypertension

Joint Problems

Juvenile Rheumatoid Arthritis

Leg Problems

Lyme Disease

Neck Problems

Neuritis

Orthopedic Problems

Paralysis

Poor Appetite

Ruptures/Hernias

Scoliosis

Sinus Trouble

Walking Problems

Has your child ever experienced any significant falls or head trauma?

Yes

If yes, please list the date and describe:

Pregnancy History

Did you experience any complications during your pregnancy? Check All That Apply:

Back/Other Pain

Fatigue

Gestational Diabetes

Nausea/Vomiting

Pre-Term

Pre/Eclampsia

Strep B

Swelling

Other complications not listed above, please list and describe:

Birth History

Type of Birth? Check All That Apply:

Antibiotics

Birth Center

Breech

Cesarean

Congenital Anomalies

Epidural

Extended Hospitalization

Failure to Thrive

Forcep

Home

Hospital

Jaundice

Meconium

Normal/Vaginal

Other

Respiratory Distress

Scheduled/Induced

Vacuum

Did you experience any problems during labor and/or delivery?

Yes

Please describe any problems during labor and/or delivery:

Hours of Active Labor:

Growth & Development

Infant Feeding: Check All That Apply:

Breast

Bottle

Formula

Number of hours of sleep each night:

Quality of Sleep:

At what age did your child respond to sound:

At what age did your child crawl:

At what age did your child hold head up:

At what age did your child stand:

At what age did your child sit unsupported:

At what age did your child walk unsupported:

Childhood Diseases, Illnesses & Vaccinations

Has your child had any of the following? Check All That Apply:

Chicken Pox

Measles

Mumps

Pertussis/Whooping Cough

Rubella

Rubeola

Have you vaccinated your child? Check All That Apply:

Yes

As Scheduled

Delayed Schedule

Allergies, Medications, Surgeries & Family History

Does your child have any allergies? If yes, please list:

Has your child had any surgeries? If yes, please list the date and describe:

Is your child taking any medications? If yes, please list the date and describe:

Do you have a family history of anything listed above? If yes, please describe:

Siblings

How many children do you have?

Number of pregnancies?

Children's Ages:

Have all your children been checked professionally for scoliosis (spinal curvature)?

Yes

Please any health concerns about your other children below?

Do you have any health concerns about your other children?

Yes

Are you or your spouse currently pregnant?

Yes

Due Date:

MM slash DD slash YYYY

Do you have any health concerns regarding this pregnancy?

Your Family Doctor's Information

Name of Your Family Doctor:

Address of Your Family Doctor's Office:

Street Address Address Line 2 City State ZIP Code

Health Insurance Information

Primary Insurance Company:

Subscriber's Name:

Subscriber's Employer:

Subscriber's ID:

Group ID:

Subscriber's Date of Birth:

Month

Day

Year

Address Where to Send Claims (Should Be Located on Back of Insurance Card):

Customer Service Phone # is located on the back of your health insurance card.
Please DO NOT enter the # 1 at the beginning of the phone number.

Address Where to Send Claims (Located on Back of Insurance Card):

Street Address Address Line 2 City State ZIP Code

Address located on the back of your health insurance card.

Do you have any of the following?

Flexible Spending Account (FSA)

Health Reimbursement Account (HRA)

Health Savings Account (HSA)

Are you covered by an additional insurance company?

Yes

Secondary Insurance Company:

Subscriber's Name:

Subscriber's Employer:

Subscriber's ID:

Group ID:

Subscriber's Date of Birth:

YYYY

Customer Service Phone # (Located on Back of Insurance Card):

Customer Service Phone # is located on the back of your health insurance card.
Please DO NOT enter the # 1 at the beginning of the phone number.

Address Where to Send Claims (Should Be Located on Back of Insurance Card):

Street Address Address Line 2 City State ZIP Code

Address located on the back of your health insurance card.

Do you have any of the following?

Flexible Spending Account (FSA)

Health Reimbursement Account (HRA)

Health Savings Account (HSA)

Assignment, Release of Benefits and Guarantee of Payment

By clicking the button below, I certify that to the best of my knowledge the information on this form is accurate, truthful and current. I certify that I, and/or my dependent(s) have insurance coverage with the aforementioned company(s) and assign directly to Herd Chiropractic Clinic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that 1) I am financially responsible for all charges whether or not paid by insurance and 2) I am financially responsible for any legal fees or other fees incurred by Herd Chiropractic Clinic for collection efforts of delinquent balances on my and/or my dependent(s) account(s). I authorize the use of my signature on all insurance submissions. Herd Chiropractic Clinic may use my healthcare information and may disclose such information to the above-named insurance company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. The consent will end when my current treatment plan is completed or one year from the date below. I consent to treatment for myself and/or treatment of my minor dependent(s) and guarantee payment for all services rendered by Herd Chiropractic Clinic whether insurance pays or not.

Acceptance of Assignment, Release of Benefits and Guarantee of Payment*

I have read and accept the above terms.

I do not accept the above terms.

Notice of Privacy Practices

I acknowledge that I have had the opportunity to review Herd Chiropractic Clinic’s "Notice of Privacy Practices" on the practice’s website online. I understand I have a right to review Herd Chiropractic Clinic’s Office Privacy Policy prior to accepting this document. The Notice of Privacy Practices describes the types of uses and disclosures of protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Herd Chiropractic Clinic. The Notice of Privacy Practices is also provided on request at the main administration desk of the practice. This Notice of Privacy Practices describes my rights and Herd Chiropractic Clinic’s duties with respect to my protected health information. Herd Chiropractic Clinic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy to be sent in the mail, email or asking for one at the time of my next appointment.

Acceptance of Notice of Privacy Practices*

I have read and accept the above terms.

I do not accept the above terms.

Terms of Acceptance/Informed Consent

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis. Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events per one million persons per year and risk of death has been estimated as 104 per one million users. It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit. I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office. I authorize Herd Chiropractic Clinic to electronically send me announcements, notices, updates, patient education and office related correspondence and other useful information related to our practice and services using electronic communications mediums including, but not limited to, the internet, email, phone, text messaging, video and voicemail.

Acceptance of Terms of Acceptance/Informed Consent*

I have read and accept the above terms.

I do not accept the above terms.

Consent to Treatment, Payment Guarantee, and Release of Information

I hereby consent to examination and all treatments of myself or my minor dependent(s) for whom I am responsible. I guarantee payment for all services rendered regardless of my results or whether my insurance company(s) contributes or does not contribute toward payment for my care or care of minor dependent(s). I authorize Herd Chiropractic Clinic to release my health and personal information for the purposes of billing, insurance submission, doctor referrals, insurance requests, test results, governmental agencies, etc. as required by law and allowed by law. Patient agrees to pay all fees if it becomes necessary to enlist a collection agency or law firm to collect a past due balance. Patient agrees to be responsible for all costs of collection on unpaid balances including, but not limited to, 1.5% interest (18% annually), collection fees (up to 50%), court costs and reasonable attorney fees.

Acceptance of Consent to Treatment, Payment Guarantee, and Release of Information*

I have read and accept the above terms.

I do not accept the above terms.

Additional Consent to Treatment of Minor

I, the undersigned, being the parent and/or legal guardian of the above-referenced minor(s) consent to and request that he/she be examined, evaluated and treated at this office within the scope of Doctor of Chiropractic (D.C.) services rendered which may include but are not limited to x-rays, examinations, evaluations, diagnoses, and treatment as chiropractically indicated and/or are recommended or directed by our Doctor(s) of Chiropractic or other qualified staff of Herd Chiropractic Clinic This consent shall be valid from this date forward until this applicable case is resolved or withdrawn by the undersigned. I, the undersigned, understand that I am responsible for, and agree to pay for any and all outstanding monies due for services rendered hereunder and understand that I must notify Herd Chiropractic Clinic IN WRITING of my intent to withdraw my consent.

Acceptance of Additional Consent to Treatment of Minor*

I have read and accept the above terms.

I do not accept the above terms.

Name

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