pediatric intake history 1 · qrespiratory distress qextended hospitalization qsunction cup or...

Pediatric Intake & History—1

FAMILY FIRST CHIROPRACTIC RENO 9476 Double R Blvd, Ste A l SPARKS 2155 Green Vista Dr, Ste 202 l FFCwecare.com

Patient Name: ________________________________________________ Date: ________________________ DOB:___________________

PATIENT INFORMATION

Address _______________________________________________________________

City, State, Zip __________________________________________________________

Phone (H) _____________________________________________________________

Phone (C) _____________________________________________________________

Email _________________________________________________________________

q Male q Female Age _____________ Birthday ________________

IN CASE OF EMERGENCY, CONTACT

Name _________________________________________________________________

Relationship ___________________________________________________________

Contact Number ________________________________________________________

Mother’s Name _______________________________________________________

Mother’s DOB __________________________________________________________

Mother’s Occupation ____________________________________________________

Mother’s Phone _________________________________________________________

Mother’s Email _________________________________________________________

Father’s Name __________________________________________________________

Father’s DOB ___________________________________________________________

Father’s Occupation _____________________________________________________

Father’s Phone __________________________________________________________

Father’s Email __________________________________________________________

Who may we thank for referring you? _____________________________________HOW CAN WE HELP YOUR CHILD?

qWellness Checkup qOther ___________________________________________________________________

________________________________________________________________________________________________

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

________________________________________________________________________________________________

________________________________________________________________________________________________

Has your child been treated on an emergency basis? qNo qYes Please describe ___________________

________________________________________________________________________________________________

________________________________________________________________________________________________

What are your goals for care: ________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

P–PainT–TenderN–NumbS–SpasmX–ShootingB–Burning

PREGNANCY HISTORYDid you experience any complications during your pregnancy? (check all that apply)

qBack/Other Pain qGestational Diabetes qPre/Eclampsia qStrep B qFatigue

qPre-Term qNausea/Vomitting qSwelling qOther ___________________________________________________________________

q3rd Trimester Presentation: qVertex qBreech qTransverse qFace/Brow

BIRTH HISTORYType of birth (check all that apply)

qHospital qBirth Center qHome qNormal/Vaginal qBreech qCesarean qScheduled/Induced

qEpidural qForceps qSunction Cup or Vacuum

Problems during labor/delivery? ____________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

qAntibiotics qCongenital Anomalies qFailure to Thrive qJaundice qMeconium

qRespiratory Distress qExtended Hospitalization qSunction Cup or Vacuum qOther __________________________________________________

Pediatric Intake & History—2


GROWTH & DEVELOPMENTInfant feeding (provide length of time)

qBreast: weeks _______ months _______ qBottle: weeks _______ months _______ qFormula: weeks _______ months _______

Number of hours of sleep each night _______ Quality of sleep q Good qFair qPoor

At what age did the child: Respond to sound __________ Crawl __________ Hold head up __________

Stand __________ Sit unsupported __________ Walk unsupported __________

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONSIndicate if your child has had any of the following diseases (check all that apply)

qChicken Pox qMeasles qRubeola qMumps qRubella qPertussis/Whooping Cough

Indicate if you r child has ever suffered from any of the following (check all that apply)

qAllergies qBroken Bones qDigestive Issues qJeuvenile * Poor Appetite(constipation / diarrhea) Rheumatoid Arthritis

qAnemia qChronic Ear Aches qDizziness qJoint Problems * Ruptures/Hernias

qArm Problems qColds/Flu qFainting qLeg Problems * Sinus Trouble

qAsthma qColic qHeadaches qNeck Problems * Tuberculosis

qBack Aches qConvulsions/Seizures qHeart Trouble qNeuritis *Walking Problems

qBed Wetting qDelayed Speech qHyperactivity qOrthopedic Problems * Other ______________________

qBehavioral Problems qDiabetes qHypertension qParalysis ____________________________

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORYALLERGIES (list) _________________________________________________________

______________________________________________________________________

______________________________________________________________________

SURGERIES (list) _________________________________________________________

______________________________________________________________________

______________________________________________________________________

MEDICATIONS (list) ______________________________________________________

______________________________________________________________________

______________________________________________________________________

FAMILY HISTORY (list) ____________________________________________________

______________________________________________________________________

______________________________________________________________________

Obstetrician/Midwife _____________________________________________________________________________________________________________________________

Pediatrician/Family MD _______________________________________________________________________________________________________________________

Date of Last Visit __________________ Purpose _______________________________________________________________________________________________________

Vaccination History _____________________________________________________________________________________________________________________________

Number of doses of antibiotcs your child has taken: During the past six months ________ During his/her lifetime ________

Previous Chiropractor _____________________________________________________________________________________________________________________________

Date of Last Visit __________________ Purpose _______________________________________________________________________________________________________

Has your child ever been treated on an emergency basis? ________ If yes, please explain: _______________________________________________________________________

Purpose of this appointment ________________________________________________________________________________________________________________________

Insurance/billing information ______________________________________________________________________ Policy # __________________________________________

AUTHORIZATION FOR CARE OF MINOR

Signed ____________________________________________________________ Witnessed _________________________________________ Date __________________

I hereby authorize this office and its doctor(s) to administer care as they so deem necessary to my son/daughter/ward (upon approval of parent or guardian).I realize that I am responsible for all fees charged by this office and I agree to pay for all services provided.

Signed ______________________________________________________________________ Date _________________________

Patient Name: ________________________________________________ Date: ________________________ DOB:___________________

Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program

First Name: _______________________________Last Name: ______________________________

Preferred Language: _______________ D.O.B.___/____/_______ Sex: _________

Sex at Birth:______________

Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never

Smoked CMS requires providers to report both race and ethnicity If yes, start date:____________

Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White

(Caucasian) Native Hawaiian or Pacific Islander / Other / I Decline to Answer

Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer

I choose to decline receipt of my clinical summary after every visit.

Patient Signature: Date:

For office use only

Height: ________ Weight: _________ Blood Pressure: _______/_______ Pulse:________

Patient Name: ________________________ D.O.B.:____________________ Date:______________________

Financial Policies S:\090101 Revised 5-22-19

Financial Policies

Proof of Insurance: New patients must complete our new patient information forms before seeing a doctor. We must obtain a copy of your picture ID and current insurance card to have proof of insurance. If you do not provide us with the correct insurance information in a timely manner, you will be responsible for any balance accrued. If your insurance lapses or expires we require full payment within 10 days unless you provide proof of valid insurance coverage. Self-Pay: Patients without health coverage are expected to make payment in full at the time services

are rendered. Any Plan Discounts can only be applied to services paid at the time the services/plans are rendered/initiated. A service charge of 15.00% per annum may be applied to all unpaid balances over sixty days. Financial Hardship is only available upon proof of said hardship and exclusively at the discretion of the doctor.

Health Insurance: Co-payments, Co-insurance and Deductible amounts are due at the time services are

rendered. Services that are not covered by your health plan are due at the time services are rendered. Services rendered beyond your policy limits become your responsibility are due within ten days. Any amounts not covered by your health plan that are your responsibility and are due within ten days. A service charge of 15.00% per annum may be applied to all unpaid balances over sixty days.

Medicare: Deductible and/or Co-Insurance is due at time of service when no secondary insurance

coverage is available, or benefits cannot be verified. Services not statutorily covered by the Medicare Program are due at the time services are rendered. An Advance Beneficiary Notice will be required for all services not covered or not believed to be covered. Deductibles will be billed and shall be due within ten days. A service charge of 15.00% per annum may be applied to all unpaid balances over sixty days.

In-network plans: I understand Family First Chiropractic will submit claims on by behalf and prepare any necessary reports and forms to assist me in making collection from the insurance company. Family First Chiropractic will accept direct assignment of benefits under this policy and will credit any payments received from insurance company to your account. I have read and understand the above Financial Policy fully understand that I am ultimately responsible for payment of all services and any costs associated with the collections including but not limited to service charges and other fees for any balance due at to the above office and doctor. ________________________________________________________ _________________ Signature of patient or authorized representative Date ________________________________________________________ ___________________ Authorized Representative Name Printed Relationship to patient

Consent for Care and Privacy Notice Acknowledgment S:\090101 Revised 5-29-19

Patient Name: ______________________________ DOB: __________________ Date: ______________

Consent for Care

The process of determining suitability of Chiropractic Services involves answering fully and truthfully all questions presented to you either written or spoken regarding your past and present health conditions during the Consultation.

If warranted, a physical examination will be performed that can include but is not limited to: vitals measurement, systems evaluation, orthopedic tests and maneuvers (tests that move and stress joints of the body), neurological test (tests using sharp or dull instruments, smells or sounds, gently tapping tendons) as well as physical touching. These test and maneuvers will help the Chiropractor determine what may be causing your complaints. Occasionally some temporary soreness and/or stiffness may occur due to the examination; less frequently aggravation of presenting symptoms or initiation of new symptoms.

Radiographs (X Rays) may be taken or ordered to further the Chiropractor’s understanding of the underlying condition, positions and alignment of the spine and associated structures. There is limited but present risk to radiation exposure. If you are or think you may be pregnant alert the Chiropractor and/or X ray lab technician; X Rays are not allowed to pregnant women in any trimester.

Privacy Notice Acknowledgement

We are concerned with protecting your privacy, especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a copy of our privacy policies and procedures. We encourage you to read this document carefully, for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have any questions or concerns regarding the use or dissemination of your personal health information, we would be happy to address them.

I consent to the performance of the above-mentioned procedures performed by the doctor involved in my case: ____ YES _____ NO

I acknowledge that I have been offered a copy of Family First Chiropractic’s Notice of Privacy Practices for Protected Health Information.

Patient Signature: ________________________________________ Date:________________

Witness Signature: ________________________________________Date:________________

DERIFIELD

+DL +DR-DL -DR

APEX

R L


Biostructural Exam Visualization, Instrumentation, Static Palpation, Motion Palpation

Patient Name: _______________________________________________ Date: ________________________ DOB:____________________

Dom HandDemeanorBPPulse (bpm)/HeartRespiration (bpm)/LungsHeightWeightCERVICAL N

Flexion (50)Extension (55)L Lat Flextion (45)R Lat Flextion (45)L Rotation (80)R ROTATION (80)CervComp (neutral)CervComp (L) (R)DistractionL Shldr DeprR Shldr DeprLindersO’Donahue’sLUMBO-DORSAL N

Flexion (70)Extension (30)L LatFlex (30)R LatFlex (30)L L-DRot (30)R L-DRot (30)AntalgiaKempsAdamsRomberg

GENERAL

BicepsBrachioTricepsPatellarAchillesBabinski

Ankle ClonusDERM

C5C6C7C8T1T2L1L2L3L4L5S1

MUSCLES TESTS

C5 (deltoid)C6 (bicep)C7 (tricep)

C8T1

L1-3 (hip flx)L4L5S1

Bilat Weight

REFLEXES Left

1 2 31 2 31 2 31 2 31 2 3

tdg / abn+ -

Left

Left

5 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 1

Right

1 2 31 2 31 2 31 2 31 2 3

tdg / abn+ -

Right

Right

5 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 15 4 3 2 1

CRANIAL NERVES

III

III, IV, VIV

VIIVIIVIIIIXXXIXII

SEATEDORTHO

Slump TestValsalva

BechterewAdson’s

PRONEORTHO

NachlasEly’s

Hibb’sSpinal Perc.

SUPINEORTHO

SLRBraggards

ThomasFABER

BowstringMiligramsS-I Stretch

Olf. Sm.Occ & Lgt

GAZESen/Taste

WinkSmile

AccousGag TasteVoc Swal

SCMTongue Mov

Left

Left

Left

L R LB-lp+ -+ -+ -+ -+ -+ -

Right

Right

Right

Ct, LEx+ -+ -+ -+ -+ -+ -

EDEMA T/P RestrictionsT1T2T3T4T5T6T7T8T9T10T11T12

EDEMA T/P RestrictionsL1L2L3L4L5SI Joint L/RSacrumS2S3S4/S5Coccyx (1-4)

EDEMA T/P RestrictionsOcciput L/RC-1L/RC2C3C4C5C6C7

qqqqqqqq

PRILL TEST

ProneCSVert.Rad.Med.Lat.LC

DEGENERATION PHASE / CURVE

Cervical I II III Thoracic I II III Lumbar I II IIIC1C2C3C4C5Additional Misalignment

KEY FOR ROM

ROM

q1=76-99% q2=51-75% q3=26-50% q4=25%

PAIN

q1=Mild q2=Moderate q3=Severe

R

L

R

L

C1C2C3C4C5APOML Slope

R ConvexR SlopeL Convex

R

LConvergence Angles

Left Right

qqqqqqqq

qqqqqqqq

qqqqqqqqqqqq

qqqqqqqqqqqq

qqqqqqqqqqqq

qqqqqqqqqqq

qqqqqqqqqqq

qqqqqqqqqqq

ROM

1 2 3 41 2 3 41 2 3 41 2 3 41 2 3 41 2 3 4

PAIN

1 2 31 2 31 2 31 2 31 2 31 2 3

L R neck-lp Ct UExL R neck-lp Ct UExL R neck-lp Ct UEx

neck-lp Ct UExneck-lp Ct UEx

Right/Left

//

+Passive

ROM

1 2 3 41 2 3 41 2 3 41 2 3 41 2 3 41 2 3 4

-ActivePAIN

1 2 31 2 31 2 31 2 31 2 31 2 3

L R LB-lp Ct LEx

///

Consultation Notes


PATIENT INFORMATIONMVAs____________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Work____________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Sports_________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Children/Pregnancy______________________________________________________________________________________________

________________________________________________________________________________________________________________

Misc_________________________________________________________________________________________________________

________________________________________________________________________________________________________________

CHIEF COMPLAINT

Onset __________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Provoc _________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Palliative_________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Quality_________________________________________________________________________________________________________

Time___________________________________________________________________________________________________________

Stress__________________________________________________________________________________________________________

Referred________________________________________________________________________________________________________

Associated______________________________________________________________________________________________________

_________________________________________________________________________________________________________________

NOTES ON LIFE EFFECT

qWork s ______________________________________ qSleep

q Exercise

q Productivity

q Recreation

q Creativity

______________________________________ qSelf-care

______________________________________ qPatience

______________________________________ qEnergy

______________________________________ qRelationships

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

q Attitude ______________________________________ qOther ________________________________________

HEALTH GOALSImmediate______________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Short Term______________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Long Term _____________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Patient Name: ______________________________________________ Date: ________________________ DOB:_____________________


Phases of Care

Patient Name: _____________________________________________ Date: ______________________

INITIAL INTENSIVE CARE

Objective: to stabilize problem and stop damage

CORRECTIVE CARE

Objective: to strengthen the spine and nerve supply, and move the body back into a normal, healthy state.

WELLNESS OR MAINTENANCE CARE

Objective of Wellness Care: to continue healing trajectory to maximize health potential, and keep the body free of nerveinterference for a lifetime.

Objective of Maintenance Care: to maintain and protect new level of health and prevent back-sliding and losing gains.

Here are your recommendations for care based upon your exam findings:

Initial Intensive Care Weeks

Weeks

Weeks

x/week

x/week

x/week

x/month

BENEFITS OF THE RECOMMENDED CARE PLAN

••

x/month

x/month

Do you have a BACK or HEALTH problem?


CHIROPRACTIC PREMISESubluxations (nerve interference or damage) cause body and mind miscommunication, malfunction and dis-ease.

Your nervous system (brain, spinal cord and nerves) controls and coordinates everything in your body and mind.When your nerve energy flows abundantly without obstruction, your body and mind are 100% self-communicating, self-healing, self-regulating and robust. When subluxations (nerve interference or damage) impede nerve flow, similar to static on your cell phone, you are no longer functioning at 100% and your health and vitality are compromised.Subluxations are caused by our inability to handle 3 major stressors: physical, mental-emotional and chemical.Left uncorrected, subluxations have devastating effects upon human health and well being, leading to breakdown, malfunction and dis-ease.Our goal is to locate subluxations, remove them and their causes and allow you to heal yourself on every level.Only chiropractors are trained to correct your subluxations.

1

2

3

4

5

6

7

SPINALLEVEL

BODYREGION

C1andC2

C3

C4

C5

C6

C7

T1/2

T3

T4

T5

T6

T7

T8

T9

T10

T11/12

L1

L2

L3

L4

L5

Sacrum

Coccyx

Adjustments correct subluxations so your body heals and functions at higher levels.

headache

neck

shoulder

arm

hand

finger

upper back

mid back

low back

hip

leg

knee

ankle

foot

toe

INTERNAL ORGANS,FUNCTIONS & EFFECTS

food sensitivity,structures of the head,

sinuses

diaphragm

thyroid

sugar handling

stomach

liver

heart

lungs & bronchi

gall bladder

stomach

pancreas

spleen & immune function

liver

adrenal glands

small intestinekidney

kidneys & bladder

ileocecal valvelarge intestine

cecumappendix

endocrine glands: thyroidpancreas, liver, adrenals

colonprostate

prostate or uterus

reproductive organs

overall tone of thenervous system

COMMON INTERNAL SYMPTOMSINDICATING DIS-EASE

spacey, dizzy, low energy, memory trouble, brain fog,sore throat, colds, influenzas, ear ache, sinus problems, snoring,

insomnia, migraines, allergies, upper respiratory conditions

difficult to take a deep breath, chronic fatigue, anxiety,vertigo, shortness of breath

low = weight gain, feelings of being coldhigh = insomnia, nervousness

craving sweets, tired after eating, headaches if too long betweenmeals, emotional instability, heart palpitations

heartburn, bloating after meals, gassy, burping, trouble with fatty foods

headaches, low energy, sneezing, nightmares, burning feet

stomach pain after eating, needs antacids

sluggishness, sneezing, nightmares, burning feet

coronary heart disease, functional heart conditions,chest pain, high or low blood pressure

bronchial asthma, shortness of breath, chronic cough

heartburn, indigestion, stomach troubles, ulcers

craving sweets, indigestion, tired after eating, heart palpitations,emotional instability, headaches if too long between meals

lowered resistance, immune deficiencies,frequent colds or influenza

overwhelmed by stress, allergies, hives

digestive complaints 1-2 hours after eating, kidney troubles

decreased urine output, swollen ankles, puffy eyelids, kidney orbladder infections, high or low blood pressure, diarrhea, constipation

bad breath, flatulence, headache when sleeping too long,dark circles under the eyes, toxicity

digestive complaints 1-2 hours after eating,abdominal cramps

see organ’s primary subluxation sites: C4, C5, C7, T6, T8bladder trouble, bed wetting, irregular cycles

bowel problems, coated tongue, headaches, frequent urination

reproductive disorders, spinal curvatures

prostate problems, dysmenorrhea, PMS, leg cramps

PMS, migraine, compulsive disorders, dysmenorrhea, impotence, infertility,dyslexia, chronic depression, vertigo, epilepsy, ADHA, sensitivity to light

CervicalSpine

ThoracicSpine

LumbarSpine

Sacrum

Coccyx

C1C2C3C4C5C6C7T1

T2

T3

T4

T5

T6

T7

T8

T9

T10

T11

T12

L1

L2

L3

L4

L5

WHO DO YOU KNOW THAT NEEDS TO BE CHECKED?

Informed Consent S:\090101 Revised 05-22-19

Patient Name:________________________________ DOB: __________________

Informed Consent for Chiropractic Services

I have been informed of the following:

1. I have heard and understand the Recommendations for Care made by the doctors of Family First Chiropractic in regard to my individual case. I have received a copy of the Recommendations for care.

2. I have read and understand the office policies of Family First Chiropractic and have received a copy of the policies.

3. That the process of delivering a “Chiropractic Adjustment” may be performed manually or with an instrument to the vertebra(e) of the spine and/or associated structures (legs, arms etc.), often resulting in an audible pop or click sound;

4. As an addition to the Chiropractic Adjustment “Supportive Therapies” may be applied by the chiropractor or by staff under their direction or supervision incorporating the use of vibration, traction, motion, bracing, nutritional advice, heat, or cold;

5. I have been informed on occasion some temporary soreness and/or stiffness may occur; less frequently aggravation of presenting symptoms or initiation of new symptoms; rarely bruising, swelling, even more rare separation/fracture; and extremely rare, nerve or vascular injury may occur in conjunction with the process of a Chiropractic Adjustment. The listed possible consequences and possible complications have been explained to me by the chiropractor;

6. I acknowledge that the chiropractor has made no guarantee of a positive outcome from care; 7. I have been afforded ample opportunity for questions and answers; and 8. The condition, possible benefits, risks of the treatment procedures, options, and financial obligations

have been explained to me by the chiropractor.

Therefore, by signing below: I consent to the performance of the diagnostic and therapeutic procedures performed by the doctor and or staff under the direction and supervision of the office chiropractor(s) involved in my case; I consent to the performance of other diagnostic and therapeutic procedures in the future that may be deemed reasonable and necessary by the doctor and or staff under the direction and supervision of the office chiropractor(s) involved in my case; Patient Signature: ________________________________________ Date: ________________ Witness Signature: ________________________________________Date: ________________

pediatric intake history 1 · qrespiratory distress qextended hospitalization qsunction cup or...

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