Potomac Valley Chiropractic
12105 Darnestown Road, Suite L-8 Gaithersburg MD 20878
301-869-0006/potomacvalleychiro@yahoo.com
Infant/Children/Adolescent Intake Form
Parent and/or Legal Guardian Must Complete Form:
Patient’s Full Name:______________________________________ Today’s Date:__________________
Address:______________________________________________________________________________
Parent or Legal Guardian’s Full Name: ________________________________________________________
Is your address the same as patient’s? Yes No
If no please provide your address:__________________________________________________________
Phone Number:_____________________________ Cell Work Home
Please list one more contact person and number for patient:____________________________________
_____________________________________________________________________________________
Primary Language: __English ___Spanish Other: ________________________
Race: ___Native Hawaiian/Other Pacific Islander ____Asian ____Latino or Hispanic ____White
____Black/African American Other:_____________________
______Decline to State
Primary Care Physician Name and Phone #:_______________________________________________________
-------------------------------------------------------- INSURANCE-----------------------------------------------------------------Who is responsible for the bill? ____Self ____Health Ins ____Auto Ins ____Attorney Other:_________
Insurance Company:____________________________________________________________________
ID/Claim#:________________________________ Policy Holder Name:_______________________________
Policy Holder Relationship to Patient: _____Self
_____Spouse _____Parent Other:______________
If Auto-Adjuster Name and Number:___________________________________________________________
About the patient:
Were there any problems during pregnancy or delivery? Yes No
If yes, explain: __________________________________________________________________________
Were there any congenital anomalies or defects identified at birth or in infancy? Yes No
If yes, explain: ___________________________________________________________________________
Were developmental milestones normal (crawling, talking, etc) Yes No ___________________________
Is the patients appetite: Normal for age
Poor
Large appetite
How many hours a night does the patient sleep on average: _________________________
Has the patient had any of the following (check all that apply):
___Chicken Pox
___Measles ___Mumps ___Whooping Cough Other: __________________
Has the patient received or is receiving standard recommended immunizations? Yes No
If no, please list immunizations not received: ______________________________________________
1
Potomac Valley Chiropractic
12105 Darnestown Road, Suite L-8 Gaithersburg MD 20878
301-869-0006/potomacvalleychiro@yahoo.com
Medical History:
Patient’s Date of Birth: ____________________ Height: ______________ Weight: ______________
Please List all Allergies and if medications are prescribed:
Allergy:
Prescription
Over the Counter Medications
______________
_______________
___________________________
______________
_______________
____________________________
_______________
_________________
_____________________________
Please check all medical issues (past or present) that may apply to the patient:
__Diabetes
___Asthma
__Seizures __ Hyperactivity ___Attention Deficit Disorder
__Chronic Ear Ache __Digestive Disorders ___Anemia
___Cardiac Disorders __Hypertension
___ Paralysis ____ Behavioral Problems
_____Mental Illness ____Depression
Other: ________________________________________________________________________
Has the patient had any surgeries? Yes No If yes please list:______________________________
_______________________________________________________________________________
Is the patient on any medications?
Yes
Medication
Dose
______________
________
______________
_________
______________
__________
No medications or supplements
Duration
Prescribed By:
_______________
_______________
________________ _______________
________________ _______________
FAMILY HISTORY: Please list any significant health problems that applies:
Relationship:
Medical History/Illness
Deceased?
Cause of Death?
Mother:
____________________
________
_______________
Father:
____________________
________
_______________
Sister(s):
_____________________
________
_______________
Brother(s):
______________________
________
_______________
Maternal Grandmother: ____________________
________
_______________
Maternal Grandfather: _____________________
_________
_______________
Paternal Grandmother: _____________________ _________
_______________
Paternal Grandfather: _____________________
_________
________________
Has the patient been involved in any auto accidents? Yes No, If yes, explain_________________________
Has the patient had any serious falls, trauma or accidents? Yes No If yes, please list:___________________
__________________________________________________________________________________________
Has the patient experienced any of the following recently:
___Paralysis
___ Stomach Ache ___Fainting/Dizziness
___Vomiting
___Headaches
__ Swelling of arms, feet, legs ___Muscle spasm ___Neck Pain ___Back Pain ___Loss of Appetite
___Diarrhea ___Pain in Joints ___Poor sleep ____Anxiety Other:_______________________________
2
Potomac Valley Chiropractic
12105 Darnestown Road, Suite L-8 Gaithersburg MD 20878
301-869-0006/potomacvalleychiro@yahoo.com
Does the patient play sports?
Sport
How Many Months a Year?
How Long Has Patient Played?
_________
_______________________
_________________________
_________
_______________________
_________________________
_________
________________________ __________________________
Has the patient had any injuries related to these sports? Yes No
If Yes, please list: ______________________________________________________________________
Has the patient had any broken bones?
Yes No If yes, please list: ______________________________
Has the patient ever had hernia or ruptures? Yes No If yes please list:_______________________________
Has the patient ever have an MRI: Yes No If yes, please give date and result:________________________
_________________________________________________________________________________________________
Does the patient engage in any of the following activities on a regular basis?
___Ice Skate ___Use trampoline ____Ride Bicycle ____Ride Moped or Dirt bike ____Roller-skate
____Swim
___Weight Lift ___Jog or Run ____Rock Climb Other:______________________________
How many hours a day does the patient use a computer or electronic device: _________________________
Does the patient carry a back pack to school? Yes No
Weight of Back Pack:_____________________
Has the patient ever received chiropractic care before? Yes
No
Has the patient been seen by anyone else for his current complaint/injury? Yes No
If yes, please list the doctor’s seen: _________________________________________________________________
Please tell us any information about the patient that you feel is important that Dr. Theodore know:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
3
Potomac Valley Chiropractic
12105 Darnestown Road, Suite L-8 Gaithersburg MD 20878
301-869-0006/potomacvalleychiro@yahoo.com
Patient Name: ___________________________________________ Date:________________
Please give a brief description of the problem(s) you are experiencing:__________________________
____________________________________________________________________________________
Describe how this/these problems affects your daily activities such as walking, exercise, work or child care
______________________________________________________________________________________
Problem Area #1:
What date did the problem start:_________________________________________________
What caused the problem (if known):______________________________________________
Is/are the problems getting better ? Yes No
Getting worse?
Yes No
Have you or are you seeing any other providers for these problems? ______________________ ________
Where is the problem the worst?__________________ Which side: Right Left Both
Did the problem start: Suddenly Gradually
Its Chronic
How does it feel (circle all that apply): Achy Dull Stiff Sharp Throbbing Other:____________
Rate your current pain level: (No pain) 0 1 2 3 4 5 6 7 8 9 10 (Bad Pain)
How does the pain feel at its best? (No pain) 0 1 2 3 4 5 6 7 8 9 10 (Bad Pain)
How does the pain feel at its worst? (No pain) 0 1 2 3 4 5 6 7 8 9 10 (Bad Pain)
Does the Pain travel or radiate? Yes No Is the Pain: Constant Frequent Occasional Intermittent
Please color in or “X” the area
(s) where you experience pain
or discomfort
Front
Back
Do you experience numbness? Yes No
If Yes, where? _______________________
Do you experience spasms?
Yes No
If Yes, where? ________________________
Do you experience weakness? Yes No If yes, where?________________________
When is the pain worse? Morning Afternoon Night Gets worse as day goes on Stays the same
What makes the pain worse? Sleeping Walking Standing Bending Driving Sitting Other:_______________
What makes the pain better? Rest Sleep Ice Heat Medication Sitting Massage
Other:_______________
Do you have any history of: Low back pain: Yes No
Neck Pain:
Yes No
Spinal or Neck Surgeries: Yes No If yes, please explain________________________________________
I have completed all this information to the best of my ability. I understand I am financially responsible for all
services that are not covered by insurance, including co-pays and deductibles.
Signature: _______________________________________ Date: ________________________
If under 18 years old, a parent or legal guardian must complete and sign forms.
4