Pediatric Intake & History —1 F AMILY 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 – Pain T –Tender N – Numb S – Spasm X – Shooting B – Burning PREGNANCY HISTORY Did 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 HISTORY Type of birth (check all that apply) qHospital q Birth 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 __________________________________________________
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Pediatric Intake History 1 · qRespiratory Distress qExtended Hospitalization qSunction Cup or Vacuum qOther _____ Pediatric Intake & History — 2 F AMILY F IRST C HIROPRACTIC RENO
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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
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 _________________________
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
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.
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?
FAMILY FIRST CHIROPRACTIC RENO 9476 Double R Blvd, Ste A l SPARKS 2155 Green Vista Dr, Ste 202 l FFCwecare.com
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.
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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.
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: ________________