Home
Our Doctor
Services
Contact Us
385-404-5489
Home
Our Doctor
Services
Contact Us
385-404-5489
Child Patient Information
Patient Information
Patient Name
*
Gender
Male
Female
Social Security Number
Birth Date
Date Format: MM slash DD slash YYYY
Age
Home Address
City
State
Zip
Primary Phone Number
Phone Type
Home
Cell
E-mail Address
School
Grade
List any sports or extracurricular activities
Siblings (names and ages)
Parent/Guardian Information
Parents' Marital Status
Single
Married
Divorced
Widowed
Significant Other
Relation
Mother
Step-Mother
Father
Step-Father
Guardian
Other
Name
Social Security Number
Birth Date
Date Format: MM slash DD slash YYYY
Driver's License Number
Address (if different than child's)
City
State
Zip
Phone Number
Phone Type
Home
Cell
Secondary Phone Number
Secondary Phone Type
Home
Cell
Employer
Occupation
Relation
NA
Mother
Step-Mother
Father
Step-Father
Guardian
Other
Name
Name
Birth Date
Date Format: MM slash DD slash YYYY
Driver's License
Address (if different than child's)
City
State
Zip
Phone
Phone Type
Home
Cell
Secondary Phone Number
Secondary Phone Type
Home
Cell
Occupation
Employer
Emergency Contact
Emergency Contact Name (other than parent)
Phone Number
Relation to child
Address
City
State
Zip
Person(s) OK to release appointment or medically related information to concerning child.
Relation
Insurance Information
Primary Insurance Company
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation
Policy Holder's Social Security Number
Policy Holder's Birth Date
Date Format: MM slash DD slash YYYY
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Secondary Insurance Company
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation
Policy Holder's Social Security Number
Policy Holder's Birth Date
Date Format: MM slash DD slash YYYY
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Dental History
How did you hear about our Practice?
Ad
Internet
Family or Friend
Physician
Other
Name of person referring (if applicable)
Has your child's tonsils or adenoids been removed?
Yes
No
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Yes
No
Does your child you have any missing or extra permanent teeth?
Yes
No
Has your child ever had an injury to (select all that apply):
Teeth
Mouth
Chin
Does your child have speech problems?
Yes
No
If so, explain:
Does your child currently or has your child ever had any of the following habits?
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail biting
Thumb/Finger Sucking
Chewing/Eating Problems
Medical History
Is your child currently being treated by a physician?
Yes
No
Reason
Physician
Last Visit
Phone
Does your child have any allergies/sensitivities to medications or latex?
Yes
No
If yes, please list allergies:
Is your child currently taking any prescription or over-the-counter medications?
Yes
No
Please list, with dosage:
Has puberty and/or menstruation begun?
Yes
No
N/A
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Yes
No
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?
Yes
No
If yes, give approximate dates:
Date Format: MM slash DD slash YYYY
Is your child pregnant?
Yes
No
Nursing?
Yes
No
Taking birth control pills?
Yes
No
Check if your child has or have ever had any of the following:
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
Authorization
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Patient Signature and/or Responsible Party
Date
Date Format: MM slash DD slash YYYY
Contact Us
We're not around right now. But you can send us an email and we'll get back to you, asap.
Not readable? Change text.
I consent to Excel Chiropractic collecting my details through this form.
Send
