Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com

Please fill out this form online prior to coming for your first appointment.

Complete it as thoroughly as possible, and if you have questions we can cover them on your initial visit.

We look forward to your visit.

Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.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?
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.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
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.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
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.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:

Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.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
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
Please read the following carefully before signing.

Informed Consent

 

We encourage and support a shared decision making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgably give or withhold your consent.

 

Chiropractic is based on the science which concerns itself with the relationship between structures (primarily the spine) and function (primarily of the nervous system) and how this relationship can affect the restoration and preservation of health.

 

Adjustments are made by chiropractors in order to correct or reduce spinal and extremity joint subluxations. Vertebral subluxation is a disturbance to the nervous system and is a condition where one or more vertebra in the spine is misaligned and/or does not move properly causing interference and/or irritation to the nervous system. The primary goal in chiropractic care is the removal and/or reduction of nerve interference caused by vertebral subluxation.

 

A chiropractic examination will be performed which may include spinal and physical

examination, orthopedic and neurological testing, palpation, specialized instrumentation,

radiological examination (x-rays), and laboratory testing.

 

The chiropractic adjustment is the application of a precise movement and/or force into the spine in order to reduce or correct vertebral subluxation(s). There are a number of different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life.

 

In addition to the benefits of chiropractic care and treatment, one should also be aware of

the existence of some risks and limitations of this care. The risks are seldom high enough

to contraindicate care and all health care procedures have some risk associated with them.

 

Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, and fracture. In addition there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment.

 

I have been informed of the nature and purpose of chiropractic care, the possible

consequences of care, and the risks of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risks, consequences and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment.

 

I HAVE READ THE ABOVE PARAGRAPH. I UNDERSTAND THE

INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS

INFORMATION HAVE BEEN ANSWERED TO MY SATISFACTION. 

HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE ADJUST

TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.

 

In addition, by signing below, I give permission for the above named minor patient to be managed by the doctor even when I am not present to observe such care.

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 14 Dec 2018