2041 HARVEY AVE
KELOWNA BC
V1Y 6G7
(250) 762.5696
FAX: (250) 762.5496
PEDIATRIC HISTORY FORM
PATIENT DEMOGRAPHICS
HR#:______________________
Childs Name__________________________________________________ Today's Date _____/_____/____
Date of Birth _____/_____/______ Birth Height: _______ Birth Weight: _______
Current Weight: _____ Age: _____
Current Height: ______
Address ________________________________________________________
City _____________________ Prov _______ Postal Code ___________________ Phone (Home)_____________________
Mothers Name: ________________________Mother’s Mobile __________________________DOB____/____/____
Fathers name: ________________________Father’s Mobile___________________________DOB ____/____/____
Pediatrician/Family MD _____________________________________City &Prov ___________________________
Last Visit: ____/____/____ Reason for visit: __________________________________________________________
Who is responsible for this bill? ___________________________________________________________________
 Other (please explain):
CHILD’S CURRENT PROBLEM:
Purpose of this visit:
_____Wellness Check-up
_____Injury or Accident
_____Other
Please explain: __________________________________
If your child is experiencing Pain/Discomfort please identify where and for how long __________________________________
________________________________________________________________________________________________________
1.
When did the Problem first begin? Date ____/____/______
2. Ever had this problem before? No______ Yes______
_____Unknown
_____Gradual
_____Sudden
If yes when? ___________________________________________
3. Any bowel or bladder problems since this problem began?:
If yes,
(Describe):________________________________________________________________________________________
4. Have you seen any other doctors for this problem? No
5. How long ago? ________Days
________ Weeks
Yes
If yes who? ____________________________________
_________ Months
________Years
6. What were the results of past treatment? ________________________________________________________________
7. How is this problem NOW:  Rapidly Improving
 Improving Slowly
 About the Same
 Gradually
Worsening
 On & Off
8. Please list any medication taken for this problem: _____________________________________________________
9. Has your child ever sustained an injury playing organized sports? _______
If yes; please explain
___________________________________________________________________________________________________
__________________________________________________________________________________________________
10. Has your child ever sustained an injury in an auto accident? _______ if yes, please explain
________________________________________________________________________________________
___________________________________________________________________________________________________
HAS YOUR CHILD EVER SUFFERED FROM: mark a
Y for YES OR N No
□
Headaches
□
Orthopedic Problems
□
Digestive Disorders
□
Behavioral Problems
□
Dizziness
□
Neck Problems
□
Poor Appetite
□
ADD/ADHD
□
Fainting
□
Arm Problems
□
Stomach Aches
□
Ruptures/Hernia
□
Seizures/Convulsions
□
Leg Problems
□
Reflux
□
Muscle Pain
□
Heart Trouble
□
Joint Problems
□
Constipation
□
Growing Pains
□
Chronic Earaches
□
Backaches
□
Diarrhea
□
Allergies to___________________
□
Sinus Trouble
□
Poor Posture
□
Hypertension
□
Asthma
□
Scoliosis
□
Anemia
□
Colds/Flu
□
Walking Trouble
□
Bed Wetting
□
Colic
□
Broken Bones
□
Sleeping Problems
□
Fall in baby walker
□
Fall from bed or couch□
Fall from crib
□
Fall off swing
□
Fall off bicycle
□
Fall from high chair
Fall off slide
□
Fall down stairs
□
Fall from changing table
□
□
Fall off monkey bars
□
Fall off skateboard/skates
□
Other:
______________________
I understand that I am directly and fully responsible to Aligned Chiropractic for all fees associated with
chiropractic care my child receives.
The risks associated with exposure to ionization and spinal adjustments have been explained to me to my
complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful
consideration I do hereby request and authorize imaging studies and chiropractic adjustments for the benefit
of my minor child for whom I have the legal right to select and authorize health care services on behalf of.
 Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a
spouse/former spouse or other guardian is not required. If my authority to so select and authorize this
care should change in any way, I will immediately notify this office.
_______________________________________________________
Date
____________________
Date
______________
Parent or Legal Guardian’s Signature
Doctor Signature _________________________
JDD,DC 5/2011
Policies
1. All 1st adjustment charges are payable when services are rendered.
2. X-ray film is the property of this office. Once films are used for treatment purposes, they
cannot be released. Copies can be made if necessary.
3. Adjustments are performed in open rooms.
I understand and agree that health and accident insurance policies are an arrangement between
an insurance carrier and myself. Furthermore, I understand ALIGNED Chiropractic will prepare any
necessary reports and forms to assist in making collections from the insurance company and that
any amount authorized to be paid directly to ALIGNED Chiropractic and will be credited to my
account upon receipt. However, I clearly understand and agree that all my services rendered me
are charged directly to me and that I am personally responsible for payment.
I also understand that if I suspend or terminate my care at this office, any outstanding charges
for professional services rendered to me will be immediately due and payable. I agree that I will
be responsible for all attorney and legal fees if legal action becomes necessary to collect this
amount. I authorize ALIGNED Chiropractic to obtain a credit report if deemed necessary.
Patient Signature_______________________________________ Date_____________________
Guardian Signature Authorizing Care_______________________ Date_____________________
In Case of Emergency Notify_______________________________________________________
Relationship__________________________ Address____________________________________
Phone #______________________________
Patient Name: ________________________________________
Assignment of Insurance Benefits
I hereby authorize payment to be made directly to ALIGNED Chiropractic, of all benefits which
may be due and payable under insurance coverage for the above named patient. I authorize
utilization of this application or copies thereof for the purpose of processing claims and effecting
payments. I further acknowledge that this assignment of benefits does not in any way relieve me
of liability and that I will remain financially responsible to ALIGNED Chiropractic.
Authorization To Release Medical Record Information
ALIGNED Chiropractic is hereby authorized to disclose all or any part of the medical records on
the above named patient to such insurance companies, organizations, or agencies as may be
responsible for payment of services rendered by ALIGNED Chiropractic. This authorization I give
with full knowledge that such disclosure may contain information of a confidential nature and
may result in a denial of insurance coverage for services rendered by said ALIGNED Chiropractic.
The undersigned certifies that he / she has read and understands each of the above paragraphs
and is the patient or responsible party with the power to execute this document and accept
these terms.
Signature of Witness: ________________________________________________
Signature of Patient or Responsible Party: ______________________________
THIS DOCUMENT CONSTITUTES INFORMED CONSENT FOR CHIROPRACTIC CARE
When a patient seeks chiropractic health care and we accept a patient for such care, it
is essential for both of us to be working toward the same objective.
Chiropractic had only one goal. It is important for each patient to understand both the
objective and the method that will be used to attain it. This will prevent 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
adjustment of the spine.
Health: A state of optimal, physical, mental and social well-being, not merely the
absence of disease of infirmity.
Vertebral Subluxations:
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 chiropractic spinal examination we
encounter non-chiropractic or unusual findings, we will so advise you. If you desire
advice, diagnosis or treatment for those findings, we will recommend that you seek the
services of the 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 to the body’s innate wisdom. Our
only method is the specific adjustment of vertebral subluxations. However, we may use
other procedures to help your body hold the adjustments.
In case of emergency, notify _____________________Phone #______________________
I, _______________________________________have read and fully understand the
above statements. I therefore accept chiropractic care on that basis.
______________________________________ ___________________
(Print Name)
(Signature) (Date)
COMPLETE IF THE PATIENT IS A MINOR CHILD:
Child’s name: _________________________________________
I___________________________________, being the parent or legal guardian of the
(Parent/Guardian Print Name)
aforementioned child have read and fully understand the above terms of acceptance and
hereby grant permission for my child to receive chiropractic care.
_________________________________________ ___________________________
(Parent’s/Guardian’s Signature) (Date)