Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.com

Welcome! This is what you can expect at your childs upcoming visits.

PAPERWORK

Please complete this simple admittance Form so we have an
understanding of their past and current health situation.

CONSULTATION

 You will meet the doctor and discuss your health concerns.

EXAMINATION

We will conduct a thorough examination to locate the cause
of the problem and determine if you are a candidate for
chiropractic care. This includes a computerized assessment
of how well your nervous system is communicating with your
body. The assessment will include range of motion, surface
electromyography, which evaluates muscle function and balance
and an orthopaedic assessment. The doctor may also need additional
procedures, such as x-rays. If this is a chiropractic case,

we will develop a plan to help.

REPORT OF FINDINGS

During the second visit, the doctor will explain the
results of the examination. If we think that we can help,
we will recommend a schedule of care created just for you. During
this time we will also explain our financial policies and determine
insurance coverage, if applicable.

HEALTH TALK

We find that when patients are empowered to help themselves,
they respond faster to care and remain healthier longer.
If we decide to accept your case part of the care involves an
opportunity to attend our health talk.

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

Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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?
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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:

Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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 case for chiropractic care,
I acknowledge and understand that I 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 by the Chiropractor indicated
below, or any party authorized to do so by that Chiropractor.

I have had the opportunity to discuss with the Doctor of Chiropractic
indicated below, or with any party authorized to do so by that Chiropractor,
about the nature and purpose of Chiropractic adjustments and other procedures.
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. The risk of stroke after
cervical adjustment is estimated at 1 in 1,000,000, substantially lower
than that associated with any medical or other treatment medications or
procedures for the same symptoms. To put this in perspective, studies
that have assessed the risk from interventions a non-Chiropractor
commonly uses for the same complaints have found the following:

Risk of paralysis or stroke from surgeries for neck pain: 15,600 per million   
Risk of death from surgeries for neck pain: 6,900 per million
Risk of serious gastrointestinal event from non-steroidal
anti-inflammatory drugs: 1,000 per million

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. 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 account on receipt. However, I clearly understand
and agree that all services rendered to me are charged directly to me and that I am
personally responsible for payment. I also understand that if I suspend or terminate
my care at this office, any outstanding charges for professional services rendered
me will be immediately due and payable.
I have read and understood the above, and I have had sufficient opportunity to discuss
its content with the Doctor of Chiropractic indicated below. I do hereby request and
consent to all examinations and care as deemed appropriate by the Doctor of Chiropractic
indicated below, for my present condition and for any future conditions for which I
may seek care. I also agree to payment for all services rendered.

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 16 Nov 2018