New Pediatric Entrance Form

GENERAL INFORMATION

PERSONAL INFORMATION

Address

Address
Address

PARENTS INFOMATION

MORE INFORMATION

Type Of Birth
Birth Location

Is the Patient 18 years or older?

Is the Patient 18 years or older?

Are you new patient?

New Patient

New Practice Member

Marital Status
Your body is designed to be healthy. Unfortunately, life happens and various events damage your health. This case history will help us at Palmetto Chiropractic understand how we can get you back to your healthy state. Please
remember, just as it was a process to becoming unhealthy, it will be a process to becoming healthy again.
Reason for last visit
Have you ever been taught how to maintain a healthy spine and nervous system?
Have you ever been placed on a health maintenance plan?

PURPOSE FOR YOUR APPOINTMENT & CURRENT SYMPTOMS

Have you had this problem before?
Is the problem
Is the problem
Is it the worst in the
Is it interferring with
Is it interferring with
Is it interferring with any of the following hobbies?

PURPOSE FOR YOUR APPOINTMENT & CURRENT SYMPTOMS CONTINUED

What helps the problem?
Checkboxes
Other indicators of ill health
Accidents & Trauma

CURRENT HEALTH HABITS

Life presents chemical, physical, & mental stresses that have a major influence on our health. Please check all that apply to your current lifestyle.

sleeping habits

TERMS OF ACCEPTANCE

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both the patient and doctor to be working towards the same objective. Chiropractic has only one goal. It is important that
each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental and social well-being not merely the absence of infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column, which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a
lessening of the body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will
advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the
body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.

New Pediatric Entrance

Type Of Birth
Location Of Birth
Is there any history of trauma, falls, or surgery?

GENERAL INFORMATION CONTINUED

Infant feeding
Quality

TERMS OF ACCEPTANCE

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both the patient and doctor to be working towards the same objective. Chiropractic has only one goal. It is important that
each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental and social well-being not merely the absence of infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column, which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a
lessening of the body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will
advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the
body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

Consent to evaluate end adjust a minor child
Pregnancy Release

This is to certify that to the best of my knowledge I am not pregnant, and the above doctors and their associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn
child.

Note: This is an appointment request form and not a guaranteed appointment. Upon receipt, you will be contacted to schedule and confirm your actual appointment.