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Download patient information - Kuperus Family Chiropractic
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Patient Name______________________________________________________patient account number______________________ Pediatric New patient Information Child’s Name (and nickname): ________________________________________________________________ Address: __________________________________________________________________________________ City:____________________________________State:_____Zip:____________ Mother Full Name and Occupation_____________________________________________________________ Father Full Name and Occupation ______________________________________________________________ Phone Numbers-Home: _________________ Work: __________________ Cell: _______________ Preferred contact: Home Gender: Female Male Work Cell Date of Birth: ____________________ Race: ________________ Ethnicity_____________________ Preferred Language___________ Please list all and any medical diagnoses your child has received:_______________________________________ ______________________________________________________________________________________ Emergency Contact person (other than parent): ________________________________________________ Emergency contact phone number: ___________________________________________________________ School child is attending:___________________________________________________________________ How were you referred to our office: ________________________________________________________ Primary Care Physician: ___________________________________________________________________ INSURANCE INFORMATION Please indicate any and all insurance coverage that may be applicable in this case. Major Medical Worker’s Comp Medicare Medicaid Auto Accident Name of primary insurance company _____________________________________________ Name of secondary insurance company____________________________________________ AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payers and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I will notify the chiropractic office of any change in my status in regards to insurance information. I consent to the care including diagnostic procedures, examinations and treatment that the chiropractor designates and considers to be necessary to treat my condition. The office may be reached at [email protected] , by phone at 502-426-6715 and by fax at 502-426-6716. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. If there is anyone you do not want to receive your medical records, please inform our office. Patient signature: _______________________________________ Date: ____________________________ Kuperus Family Chiropractic, PSC Rachael A. Kuperus, DC, 7410 New LaGrange Rd, Ste. 202 Louisville, KY 40222 1 Patient Name______________________________________________________patient account number______________________ CURRENT CONDITION Major complaint/symptoms/concerns/goals in seeking Chiropractic care: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Digestive Health: Does your child have periodic loose stool/diarrhea? __YES__NO Does your child suffer from chronic constipation? __YES__NO Circle all that apply. Offensive gas/undigested food in stool/mucus in stool/Reflux/Extremely large stool/stomach pains. Is your child potty trained (both bowel and bladder)? __YES__NO Antibiotic History: Approximately how many antibiotics has your child been on in their lifetime?____________________________________ Main reason for antibiotic use: __________________________________________________________________________ Has your child ever been treated for a yeast infection? __YES__NO Diet: *If possible please bring a diet log of at least 2-3 days to initial consultation* __Gluten Free __Casein Free __Other Diet: __________________________________________________________________ What are your child’s favorite foods? __________________________________________________________________________ Are they a picky eater? _____________________________________________________________________________________ What do they typically drink? _______________________________________________________________________________ How many glasses of water a day? _________ Trauma/Surgeries: Date of last physical:_____________________________ Has your child ever been in any accidents, auto, fall down stairs, fall from ladder, or other significant trauma? __YES__NO When/Describe? _______________________________________________________________________________________ Does your child play sports?______________________________________________________________________________ List all surgeries: _______________________________________________________________________________________ List all significant illness (Mumps, measles, TB, Pneumonia etc.):_________________________________________________ _____________________________________________________________________________________________________ Please list all prescription and over-the –counter medications. Name of Medication Dosage Frequency For what condition How long have you been taking it? Prescribing MD Kuperus Family Chiropractic, PSC Rachael A. Kuperus, DC, 7410 New LaGrange Rd, Ste. 202 Louisville, KY 40222 2 Patient Name______________________________________________________patient account number______________________ Please list all supplements/vitamins/herbs your child is taking: Does your child have medication allergies? (Please list medication and reaction) __________________________________________ _____________________________________________________________________________________________________ Is your Child up to date on vaccines? __YES__NO Has your Child ever had a vaccine reaction? __YES__NO if yes explain: _________________________________________________ List all therapies your Child is currently receiving and Therapist (OT, ST, PT, Hippotherapy, Aqua, etc.): Family History Child Father side Mother side Sibling Kidney Disease Thyroid Disease Cancer Arthritis Osteoporosis Scoliosis Depression Neurological Disorder Allergies Asthma Schizophrenia Genetic Disorder OCD/Anxiety Celiac Disease Other: Birth History: Length of pregnancy: __________wks Were there any complications during pregnancy: __Seizures __High blood pressure __Diabetes __Pre-term labor__ other (please describe) ___________________________________________________________________________________________________ Describe delivery (hrs in labor, c-section/vaginal delivery, use of Pitocin, forceps or vacuum):_____________________________ ___________________________________________________________________________________________________________ Weight and length at birth: ___________________________________________________________________________________ Breastfed? (Y/N, how long, if NO, why not and list any difficulty with Breastfeeding)__________________________________ _______________________________________________________________________________________________________ Infants: Kuperus Family Chiropractic, PSC Rachael A. Kuperus, DC, 7410 New LaGrange Rd, Ste. 202 Louisville, KY 40222 3 Patient Name______________________________________________________patient account number______________________ Does your Infant have a preferred head position? Y/N__________ Does your Infant cry during a diaper change? Y/N______________ Does your infant hate belly time? Y/N_______________________ Does your infant arch his/her neck backwards? Y/N ____________ Check all that apply: __Colic __Abnormal head shape __Diaper Rash __Torticollis __Congenital Hip Dysplasia __Acid Reflux __Toe walking __Head banging __Stimming __Headaches __Staring spells __restless sleeping __verbal delay __vision issues __growing pains __hypotonic __Food allergies __Clumsy __stomach aches __bed wetting __Asthma __Eczema __teeth grinding __Back/Neck Pain __Chronic Ear Infection Please list the approximate age when your child achieved the following milestones First introduced to solids: _________________ Sat on own: _____________________________ Crawled: _________________________ Describe abnormal crawl patterns:___________________________________________ Walked: __________________________ First Word:________________________ Use the following space to list ANYTHING else you think is important and want the Doctor to know: I verify all the information I have provided on this form is true and correct to the best of my knowledge. Signature of parent or guardian:___________________________________________________Date:_____ Kuperus Family Chiropractic, PSC Rachael A. Kuperus, DC, 7410 New LaGrange Rd, Ste. 202 Louisville, KY 40222 4
