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New Patient Questionnaire- Child (12 or Younger)

Step 1 of 6

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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:*
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
- 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
- No
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
- No
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:
- No
- 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
- No
Do you have any health concerns about your other children?
Are you or your spouse currently pregnant?
- No
- 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:*
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 (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
- No
Secondary Insurance Company:
Subscriber's Name:
Subscriber's Employer:
Subscriber's ID:
Group ID:
Subscriber's Date of Birth:
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 (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 Optimal Wellness for Life Chiropractic Center 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 Optimal Wellness for Life Chiropractic Center 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.Optimal Wellness for Life Chiropractic Center 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 Optimal Wellness for Life Chiropractic Center 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 Optimal Wellness for Life Chiropractic Center’s "Notice of Privacy Practice" on the practice’s website online. I understand I have a right to review Optimal Wellness for Life Chiropractic Center’s Complete Notice of Privacy Practices 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 Optimal Wellness for Life Chiropractic Center 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 Optimal Wellness for Life Chiropractic Center’s duties with respect to my protected health information. Optimal Wellness for Life Chiropractic Center 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
When we accept you as a patient it’s important that you understand the objectives of our care. Chiropractors provide a unique service that other healthcare providers do not offer. Chiropractors specialize in the location and correction of vertebral subluxations for the purpose of improving the health and function of your spine and nervous system. A vertebral subluxation is a misalignment or distortion of your spinal column and/or related structures that can affect your health and overall body functioning. Chiropractors spend years studying how to locate and correct this destructive condition. The correction is performed using specialized techniques called “chiropractic or spinal adjustments” over a period of time. When your spine is free of the nerve and musculoskeletal stress caused by subluxations your body can function more efficiently and your body’s natural ability to heal can work more optimally. It is not our objective to medically diagnose or treat any disease, symptom or condition. If you desire diagnosis or treatment for a specific symptom or treatment of a specific symptom, disease, or condition or advice on taking or stopping medications, we recommend you consult a healthcare provider who specializes in that area. If we discover unusual findings in the course of our chiropractic examination(s) we will let you know of them. You may then decide whether you wish to investigate further and discuss your healthcare options with other health professionals. Chiropractic, like all forms of health care, while offering considerable benefits may also provide some level of risk. This level of risk is most often very minimal. In very rare cases injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the extremely rare complications associated with spinal manipulation, occurring at a rate between one per one million to one per twelve million cervical spine (neck) adjustments is vertebral artery injury. This very rare occurrence could lead to stroke. Prior to receiving chiropractic care from Optimal Wellness for Life Chiropractic Center, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spinal health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a recommended plan of care prior to beginning care. The purpose of chiropractic care is not to treat disease or conditions, nor to suppress symptoms, nor to perform surgery or prescribe medications but rather to improve the health and function of your spine and nerve system to help your body function at it’s optimum health and healing potential. It is our sole objective to improve and maintain the health and normal function of your spine and nerve system to the maximum degree possible for you.
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 Optimal Wellness for Life Chiropractic Center to release my health and personal information for the purposes of billing, insurance submission, doctor referrals, insurance requests, employer test results, governmental agencies, etc. as required by law and allowed by law.
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 Optimal Wellness for Life Chiropractic Center 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 Optimal Wellness for Life Chiropractic Center 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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