Chiro Child Intake Form
ADVERTISEMENT
1
2
3
4Lifetime Wellness of Boulder with Dr. Amanda Friedhoff —Chiro Child Intake Form
2503 Walnut St #100, Boulder, CO 80302 (303) 578-0771
Child’s Name: __________________________________________________________________ Date: _____________
DOB: ____/____/____ Age: _______
Male
Female Height: _______ Weight: __________
Parent’s Names: ___________________________________________________________________________________
Sibling’s names and ages: __________________________________________________________________________
Address: _____________________________________________ City: _____________ State: ______ Zip: ________
Mom’s Cell #: _________________________________ Dad’s Cell #: _______________________________________
Other Important numbers: ________________________________________________________________________
Email addresses: ___________________________________________________________________________________
Insurance:
Self-Pay
Auto Injury
Health Insurance (Which?) ___________________________
How did you hear about us?
Referral: ______________________ Internet/Other: ____________________
Has your child been to a chiropractor before?
Yes
No
Has your child experienced any of the following? Please check if so:
Asthma
Colic
Neck pain
Allergies
Acid Reflux
Shoulder pain
Ear Infections
Digestive Issues
Arm/Wrist pain
Sinus Congestion
Low Energy
Back pain
Headaches
Recurring Fevers
Scoliosis
Dizziness
Seizures
Tingling in Arms/Legs
Anxiety/Easily Agitated
Chronic Colds
Foot/Ankle/Knee pain
ADHD/Hyperactivity
Bed Wetting
“Growing Pains”
Sleeping Problems
Other Issues: ________________________________________________
Which of these problems checked off is the worst? ________________________________________________
How long has it been going on? __________________________________________________________________________
Is it constant/ intermittent/ cyclical? ___________________________________________________________________
Since it started, has it gotten better/ worse/ stayed the same? _______________________________________
Does anything help? _________________________________________ Make it worse? ___________________________
Have you seen any professionals for this condition? Y N Details: _________________________________
What are your hopes / goals from today’s visit? _______________________________________________________
Medical History: please describe any incidents listed below
Car Accidents (list child’s age/treatment): ______________________________________________________________
Falls/ Fractures/ Hospitalizations: ______________________________________________________________________
Surgeries Performed: ______________________________________________________________________________________
Taking any medications? (please list reason) ___________________________________________________________
Supplements? ______________________________________________________________________________________________
Any other issues? __________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business