FERGUSON FAMILY CHIROPRACTIC CHILDREN’S HEALTH HISTORY FORM

Today’s Date______________________
ABOUT THE CHILD

Name ________________________________________ Age ______ Date of Birth ______________________________
Gender           M           F                Height  _____________________        Weight  ____________________________
Home Address ____________________________________City __________________ State ______ Zip ____________
Names and Ages of Siblings__________________________________________________________________________
Parent A	Parent B	
Name  ________________________________________	Name  ________________________________________	
Cell phone  (________) _________________________	Cell phone  (________) _________________________	
Employer ______________________________________	Employer ______________________________________	
E-mail _________________________________________	E-mail _________________________________________	

Whom may we thank for referring you to our office? ________________________________________________
Would you like to sign up for our monthly email newsletter? ____YES  ____NO
Would you be interested in signing a release to be featured on our social media? ____ YES ____ NO

REASON FOR SEEKING CHIROPRACTIC CARE
What concerns do you feel Ferguson Family Chiropractic can address for your child? ____________________________
_________________________________________________________________________________________________
Related to:    Sports      Auto       Fall       Chronic       Home Injury       Other ___________________________
 
Please describe how these concerns are affecting your child’s quality of life. ____________________________________
_________________________________________________________________________________________________

Check all that apply	  School	 		  Exercise/Sports		  Walking
  Playing	 		  Sleep 			  Attention/Focus 
  Communication 		  Eating			  Daily Routine

EXPECTATIONS OF CARE

I would like my child to experience the following benefits from Chiropractic Care: 

Check all that apply	 Symptomatic relief of pain or discomfort
			 Correction of the cause of the problem as well as relief of symptoms
			 Prevention of future problems
			 Healthier spine and nerve system
			 Optimal health on all levels
			 OTHER_____________________________________________________________________

PREGNANCY OF MOTHER & BIRTH

During pregnancy, did the mother:
 Experience any significant illnesses, difficulties, or trauma? _______________________________________________
 Take any drugs/medications? _______________________________________________________________________
 Smoke or consume alcohol

 Home birth		 Hospital birth		 Vaginal               Water birth	 Caesarean

Was the delivery premature?  No   Yes   Weeks ______________________________Weight __________________
Approximately how long did labor last? _________________ hours
Was labor artificially induced?  No   Yes _____________________________________________________________
Was it determined that the child was breech or otherwise malposition?  No    Yes ___________________________ 

The birth process can be traumatic to a baby’s spine and cause interference to the nervous system. Please check which, if any, of the following were administered during labor and birth. 

 Epidural 		 Forceps			 Vacuum		 Medications ____________________	
 Pitocin		 Episiotomy			 Manual traction of the neck  	           ____________________
 
Please check all that apply to the baby’s status immediately after birth: 

 Jaundice		  Respiratory problems   	 Broken bones  _____________________________________
 Feeding problem  	  Displaced joints 		 Other conditions ____________________________________

APGAR Score _________________________

Was the baby breastfed?  No   Yes   For how long? ____________________________________________________  

CHEMICAL STRESS

Chemical stresses can occur when a substance that is toxic to the body is breathed, injected, taken by mouth, or comes into contact with the skin. The following will reveal exposures your child may have experienced. 

Have you chosen to vaccinate your child?  No  Yes. 
If yes, please check all vaccinations the child has received and at what age they were administered:

  DPT	 __________  	 	 MMR 	__________  	  Other  _____________
 Polio	 __________       	 Chicken Pox 	__________       
  Hepatitis 	 __________   	 	 Flu 		__________     

Please describe any and all reactions to vaccine(s)________________________________________________________

Please check all that apply and give any necessary details: 
 Child exposed to second hand smoke.
 Has taken antibiotics. Explain  ______________________________________________________________________
 Currently taking medication. Explain _________________________________________________________________
 Currently taking supplements. Explain ________________________________________________________________
 Has allergies. Explain _____________________________________________________________________________
     What treatments have you used? ___________________________________________________________________

PHYSICAL STRESS: INFANCY & CHILDHOOD
Is the reason you are seeking care related to:    Sports    Auto     Fall     Chronic     Home Injury     Other
 
Please check all that apply to your child and give any necessary details:

 Uncoordinated/Accident prone
 Has been hospitalized. ____________________________________________________________________________
 Had a severe trauma.  ____________________________________________________________________________
 Been in an automobile accident.  ____________________________________________________________________
 Has fractured a bone or dislocated a joint. _____________________________________________________________
 Has/had a chronic illness. __________________________________________________________________________
 Has had surgery.  ________________________________________________________________________________

What physical activities does your child participate in? _____________________________________________________

EMOTIONAL STRESS

It is difficult to separate the emotional stress in our life from the physical response that often occurs. Please indicate if your child has ever or is currently experiencing any of the emotional stresses below:

 Academic pressure		 Loss of a loved one	          Bullying			 Relocation
 Lifestyle change		 Parents’ divorce	          Loss of a pet		 New sibling

Does your child have difficulty interacting with schoolmates or friends?  Yes    No
Have you or anyone else noticed that your child is nervous, twitches, shakes, or exhibits rocking behavior?  Yes   No 

HEALTH CARE PRACTITIONER HISTORY

Has your child ever received chiropractic care?   Y    N   Name of D.C. _____________________________________

Reason ____________________________________  How long? ________________ Date of last visit ______________

Why was care stopped? _____________________________________________________________________________

Have you consulted or do you regularly consult any of the following providers for your child? 

Check all that apply	 Medical Physician 	 	 Naturopath 		 Acupuncturist 	 Homeopath
			 Massage Therapist 		 Psychotherapist 	 Energy Healer  	 Other

Reason __________________________________________________________________________________________

_________________________________________________________________________________________________

Financial Agreement:
This agreement is to inform you of your financial obligation to our practice. This financial agreement is intended to provide excellent service to you. Payment is due at time service is rendered. You will be responsible for fees my for all services you receive. 
•	Should you discontinue care at any time you am still responsible for outstanding bills/charges.
•	If you are on a payment plan, you will be responsible for the outstanding balance for care you have already received, and have not fully paid for.  
•	I am responsible for any amounts not covered by my insurance.

Time of Service Discount Options (TOS)		               $115
TOS Re-exam			            $ 55
TOS  Medicare Exam			            $60
TOS  Spinal Adjustment		               $45
TOS Kinesio Therapy		               $15
TOS  EMS, Ultrasound, ART			            $12		
**TOS – A discounted fee that must be paid at the “Time Of Service”
**We also offer family plans for patients and their family! Please ask for more details

INSURANCE INFORMATION
 Insurance
Insurance coverage varies greatly.  We will verify chiropractic coverage specific to your plan and estimate what will be due. Payment must be made each visit for services not covered or patient responsibility amount. This is not a guarantee but only an estimate of charges not covered. Additional charges may apply based on your insurance coverage.

 Personal Pay
 Most of our patients pay for care “out of pocket”, even those with insurance reimbursement plans. Our discounted time of service plans allow you to receive all the care necessary for you to regain your health at an affordable fee. We will be happy to provide you with monthly statements for insurance reimbursement.  

 Personal Injury/accident, Worker’s Compensation Insurance 
	If you have an auto accident, a worker’s compensation injury a personal injury (or other insurance that requires direct billing) you will be expected to complete all the paperwork necessary for us to file the claim on your behalf.  If paperwork is not completed within the first week of care, you will be expected to pay for your chiropractic care.

	   PIP forms filled out.  Date of Accident__________________________________

	   Injury reported to Employer.  Date of Injury______________________________

TERMS AND CONSENT TO CARE
(Please read and sign)
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective as this prevents any confusion or disappointment.

The objective of chiropractic health care in this office is to improve and optimize the health and function of the spine and nerve system through the correction of Vertebral Subluxation. A Chiropractic Adjustment is the method used for the correction of Vertebral Subluxations.

We do not diagnose or treat disease. We analyze the spine for Vertebral Subluxations.  If during the course of a chiropractic spinal evaluation, 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. 

Our commitment to your health is to (1) evaluate and monitor your spine and nerve system on each visit to determine the adjustment and adjusting procedures that will get the best outcome for you and (2) to provide you with supportive education and information so you can make the best health choices.

The information I have provided on this case history form is true and accurate to the best of my knowledge.    
I give Dr. Brian Ferguson, Dr. Amanda Ferguson, Dr. LaRissa Tilley, Dr. Emily Rehm, Dr. Nate Betts and Dr. Peter Ferguson permission to render care to my child today.  This initial visit includes a health history consultation, chiropractic exam and evaluation, and any initial care that is determined to be clinically necessary and mutually agreed upon.

Name: (Printed) _____________________________________________Date: _______________________

Signature of Parent (for minor):_________________________________ Date: _______________________

*We kindly ask that if you need to reschedule or cancel your appointment that you give at least 24 hours notice. Thank you for understanding that our time is valuable. 

Thank you for choosing Ferguson Family Chiropractic.  
We look forward to helping you.