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Pediatric Intake Form
Child's First Name *
Your answer
Child's Last Name *
Your answer
Address *
With City / State / Zip
Your answer
Birth Date *
Your answer
Age *
Your answer
Sex *
Number of Siblings
Your answer
Sibling(s) Names & Ages
Your answer
Parents' Names
Your answer
Best Contact Phone *
Your answer
Alternate Phone
Your answer
Email *
Your answer
Who can we thank for referring you or how did you hear about us? *
Your answer
What is your reason for seeking care in our office? *
Your answer
When did this begin?
(If applicable)
MM
/
DD
/
YYYY
What is this affecting that is MOST important in your child's life? *
List all that apply
Your answer
Has your child seen any other providers for this condition? *
List all that apply
Your answer
Has your child seen a chiropractor before? *
How long ago?
Your answer
Clinic/Doctor Name
Your answer
What is your reason for the change?
(If applicable)
Your answer
What health goal, if your child were to complete or accomplish it, would have the greatest impact on his/her life? *
Your answer
Are there any major injuries and/or surgeries we should know about? *
Your answer
HEALTH CONCERNS *
Required
Is there anything else regarding your child's current condition you feel the doctor should know?
Your answer
MEDICATIONS
VITAMINS / SUPPLEMENTS
Is your child on a special diet? *
Required
PRENATAL HISTORY
Location of birth
Did any of the following happen during delivery? *
Required
Describe any of the above plus any additional complications experienced during pregnancy or delivery.
Your answer
During pregnancy, did the mother use any drugs, tobacco, alcohol, and/or medications?
If yes, please list under other.
Did the mother experience any illness while pregnant?
If yes, please list under other.
Does the mother have any of the following:
If yes, please describe under other.
Birth weight:
Your answer
Birth length
Your answer
APGAR scores
(if remembered)
Your answer
Ultrasound used during pregnancy?
Mention Number of times under other.
Was the child breastfeed?
If yes, how long? Mention in other box.
Was the child formula feed?
If yes, how long? Mention in other box.
At what age were solids introduced?
Your answer
At what age was cow's milk introduced if at all?
Your answer
LIFESTYLE HABITS
Does your child exercise daily?
How much? Mention under other box.
Does your child drink soda?
How much/often? Mention under other box.
Does your child have a positive self-esteem or self-image?
Does your child watch more than an hour of TV per day?
How much? Mention under other box.
Does your child use a tablet or other mobile device more than 1hr per day?
How much? Mention under other box.
Does your child eat balanced meals?
Does your child experience prolonged sadness?
Does your child have difficulty sleeping?
CURRENT HEALTH STATUS
The National Safety Council reports approximately 50% of children fall head first from a high place during their first year of life (bed, changing table, stairs, etc.). Was this the case for your child?
Explain in other box
Has your child ever been hospitalized or had surgery?
Explain in other box
Does your child have difficulty interacting with others?
Explain in other box
Have you noticed that your child is nervous, twitches, shakes, or exhibits rocking behavior?
Explain in other box
Has your child been involved in any high impact/contact sports (soccer, football, martial arts, cheerleading, etc.)?
list them in other box
Are you aware of any food allergies or intolerance?
Explain in other box
Has your child been vaccinated?
Explain in other box
If your child was vaccinated, did they experience any adverse reactions?
Explain in other box
Stress level at School
Please rate stress levels as on a scale of 1-10 (10 being highest)
Personal Stress level
Please rate stress levels as on a scale of 1-10 (10 being highest)
PERMISSION TO TREAT A MINOR
Give Permission to the doctor. *
Required
HIPPA POLICY
This information serves as a copy of the Notice of Privacy Practices for Protected Health Information. The Notice of Privacy Practices describes the types of uses and disclosures of my Protected Health Information (PHI) that will occur in my treatment, payment of my bills or in the performance of health care operations of this chiropractic office. You may request your own copy if you would like one.

This Notice of Privacy Practices also describes my rights and duties of the chiropractor with respect to my protected health information. I hereby give permission to Synergy Chiropractic and Dr. Eric Mintz to use and/or disclose Protected Health Information in accordance with the following:


SPECIFIC AUTHORIZATIONS:

• I give permission to Synergy Chiropractic and Dr. Eric Mintz to use my address, phone number and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, newsletters, and general information about health related items.

• If Synergy Chiropractic and Dr. Eric Mintz contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail.

• I give Synergy Chiropractic and Dr. Eric Mintz permission to provide care to me in an open room where other patients are also being cared for. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with doctor at any time in private or wish to have my treatment provided in a private setting, the doctor has available a room for this.

• By electronically signing this form you are giving Synergy Chiropractic and Dr. Eric Mintz permission to use and disclose your protected health information in accordance with the directives listed above.

The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care and health information. This authorization will remain in effect for the duration of my care at Synergy Chiropractic and Dr. Eric M CLINIC NAME plus 7 years or until revoked by me.

RIGHT TO REVOKE AUTHORIZATION:

You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization.

You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of the CLINIC NAME. The written notice must contain the following information:

Your name, Social Security number and date of birth;

A clear statement of your intent to revoke this AUTHORIZATION;

The date of your request; and

Your signature.

The revocation is not effective until it is received by the Privacy Official.

This AUTHORIZATION is requested by the CLINIC NAME for its own use/disclosure of PHI. (Minimum necessary standards apply.)

I have the right to refuse to sign this AUTHORIZATION. If I refuse to sign this AUTHORIZATION, the CLINIC NAME will not refuse to provide treatment, however, I will be responsible for 1) scheduling my own appointments since the CLINIC NAME will be unable to contact me 2) all contact with the CLINIC NAME regarding my care. Additionally, any collection activity as permitted by law is not waived by refusal to sign the authorization.

I have the right to inspect or copy, within boundaries, the protected health information to be used/disclosed. A reasonable fee for copying will apply. A copy of the signed authorization will be provided to me.

I have read and understand this Healthcare Authorization Form and acknowledge receipt of The Notice of Privacy Practices for Protected Health Information. By checking the box below, I acknowledge that I am in agreement with these practices.
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