Stittsville Child Chiropractic Forms

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Oaktree Child Chiropractic Forms

Patient Information

Patient Name*

First Name

Last Name

Patient Gender

Name of Parent(s)

Address*

Address Line 1

Address Line 2

City

Province

Postal Code

Email Address*

Cell Phone*

Home Phone

Work Phone

What is your preferred method of communication?

Call Email Text

Other:

I consent to receiving email communication from Oaktree *

Yes No

(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*

Weight:

Height:

Medical Doctor Name:

Referral:*

How did you hear about Oaktree Health?

Chiropractic History

Have you been to a Chiropractor before?*

Yes No

Were X-rays taken?

Yes No

Name of Chiropractor and City

Approximate date of last visit:

Duration and Frequency of Care:

Primary Health Concern

What is the purpose of today's visit?*

Wellness Check Up Specific Concern (Fill below)

What is the primary health concern for your child?

How long has your child had this condition?

What other health care professionals have treated this condition? What else have you tried?

Is the problem:*

Getting better Getting Worse Staying the same

Please rate the problem on how you think it is affecting your child:

Please rate the problem on how you think it is affecting your family:

Secondary Health Concern (if applicable)

What is the secondary health concern of your child?

How long has your child had this condition?

What other health care professionals have treated this condition? What else have you tried?

Is the problem:

Getting better Getting Worse Staying the same

Please rate the problem on how you think it is affecting your child:

Please rate the problem on how you think it is affecting your family:

Please share any additional health problems, concerns, or information

Chemical Stressors

Does your child have any food intolerances?*

No Yes

If yes, please list:

Has your child had any vaccines?*

No Yes

If yes, please list:

Has your child ever had antibiotics?*

No Yes

If yes, please list:

Total number of antibiotic rounds to date:

Does your child take any medication(s)? Which and for what condition(s)?

Submission

I understand that the purpose of today's visit is to determine if I am a candidate for chiropractic care and that I am responsible for any fees agreed upon by myself and the attending doctor. All examination fees will be explained to me before any tests are performed (Patients may be requested to sign a presented hard copy of this document upon arrival)*

Date*

Oaktree Child Chiropractic Forms

Patient Information

Chiropractic History

Primary Health Concern

Secondary Health Concern (if applicable)

Chemical Stressors

Traumatic Stressors

Conditions and Symptoms

Submission