WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com

Welcome to WellnessOne,

 

We strive to make your experience as smooth and efficient as possible so here is what you can expect in your visit.

 

PAPERWORK

Please complete this personal health history questionnaire form for your child.

CONSULTATION

You will have a one-on-one consultation with the doctor to discuss the health concerns that you have for your child.8


EXAMINATION

A comprehensive examination and evaluation including those tests necessary to determine the precise cause of the problem is given. The doctor will advise you if additional laboratory tests or x-rays are needed.


REPORT OF FINDINGS

If we feel we can help your child we will tell you. This will include a thorough explanation of how our treatment works and what results we feel can be obtained.  If we feel we cannot be of help to your child we will provide you with a recommendation and/or referral to another provider that we feel will be of most benefit.  

 

 

Please complete the following pages to save time and help us to serve you better. Thank you.

WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
First Name
Last Name
Address
City
Zip Code
Gender
SSN
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Complications during pregnancy?
Ultrasounds during pregnancy?
Medications during pregnancy?
Cigarette/alcohol use during pregnancy?
Location of birth:
Birth intervention performed:
Delivery medication?
Delivery complications?
Birth Weight
APGAR Scores
Birth Length
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Name of Pediatrician
Date of Last Visit
Reason
Treatment
At what age, in months, was the following introduced?
Solids:
Cows milk:
At what age was your child able to (in months):
Respond to sound
Hold head up
Crawl
Sit



Respond to visual stimuli
Stand Alone
Walk Alone


Personal Illness History
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Number of doses of antibiotics your child has taken:
Last 6 months: Since birth:
Number of doses of other prescription medications your child has taken:
Last 6 months: Since birth:
Child's daily habits (skip any questions that do not apply):
Hours of sleep per night (1-24)
Child's exercise
Average amount of time spent watching TV, playing video games, or using a computer per day:
How often does this child consume:
Caffeine Drinks:
Sugars/sweets:
Dairy Products
Wheat Products
Fruits/Vegetables
Water as a beverage:

WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Present problem:
First occurrence of condition
Did something specific cause this condition? (please describe)
Since the problem started, is it:
Does anything make it better?
Does anything make it worse?
Other health professionals seen for this problem (please list names and dates if applicable)
Chiropractor
Medical Doctor
Other
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Please read the following carefully before signing.

PLEASE READ CAREFULLY

In order for the Doctor of Chiropractic indicated below to make a 
determination on the suitability of my child case for chiropractic care, I acknowledge and understand that my child must complete a thorough chiropractic evaluation, which may include a diagnostic radiographic examination if clinically indicated. I do hereby request and consent to the performance of such an evaluation on my child indicated 
below, or any party authorized to do so by that Chiropractor.


I understand that Chiropractic care is considered very safe with an extremely low risk rate. I further understand that there are, however, some risks associated with chiropractic care, as there are with any and all healthcare treatments. In healthcare, the matter of whether any treatment is appropriate or not is determined by looking at the level of risk and comparing this with the level of expected benefit. 

In particular, I understand that in rare cases there have been reported incidents of injury to the vertebral artery during the course of care to the cervical spine by medical doctors, physiotherapists, and chiropractors. However, the proposed mechanism of this injury is reproduced by a wide variety of trivial neck movements, including turning your head to look out the back of a car, or having a shampoo at a hair salon. This injury is of concern because it may lead to a stroke.  I understand that while rare, some patients have experienced rib fractures or muscle and ligament sprains or strains following spinal adjustments. I also understand that there have been rare reported cases of disc injuries following cervical and lumbar adjustments although no scientific study has ever demonstrated such injuries are caused or may be caused by chiropractic treatment.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself and my child. Furthermore, I understand that the doctor’s office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the doctor’s office will be credited to my child or my account on receipt. However, I clearly understand and agree that all services rendered to my child are charged directly to me and that I am personally responsible for payment. I also understand that if my child terminates care at this office, any outstanding charges for professional services rendered to them will be immediately due and payable.I have read and understood the above. I do hereby request and consent to all examinations & care as I feel appropriate for my child, I also agree to payment for all services rendered.

 

 

 

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 23 Nov 2017