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Oaktree Child Chiropractic Forms

Patient Information

Patient Name*
I consent to receiving email communication from Oaktree *
(Emails we will send you include news updates from Oaktree. We will not spam you and you can unsubscribe at anytime. You will still receive appointment reminders and other important notices via email)
Patient's Date of Birth*
How did you hear about Oaktree Health?

Chiropractic History

Have you been to a Chiropractor before?*
Were -rays taken?
Approximate date of last visit:

Primary Health Concern

What is the purpose of today's visit?*
Is the problem:*

Secondary Health Concern (if applicable)

Is the problem:

Chemical Stressors

Does your child have any food intolerances?*
Has your child had any vaccines?*
Has your child ever had antibiotics?*

Traumatic Stressors

Has your child ever been hospitalized post birth? *
Has your child ever had surgery?*
Has your child ever been involved in a car accident?*
Does your child play any high impact sports?*
How often does your child participate in aerobic exercises? (as least 30 minutes per day)

Conditions and Symptoms

Conditions and Symptoms. Please check all that apply:


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