Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com

Welcome to our office!

Paediatric Intake Form

 

 

Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
First Name
Last Name
Address
City
Postal
Gender
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.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
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.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
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.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:

Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.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
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
Please read the following carefully before signing.

 

CLINICAL CONSENT, PRIVACY & INSURANCE POLICIES

Consent to Chiropractic Care & to the Collection, Use, and Disclosure of Personal Information

 

 INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE:

Physicians, Chiropractors, Osteopaths and Physiotherapists are required to advise patients of benefits and risks including sprain/strain, rib fracture, disc herniation and neck problems of the following: There have been very rare incidents of injury to the vertebral artery during the course of treatment. This has caused strokes or stroke like occurrences, which are usually of a temporary nature. The chances of this happening are rare. Tests, with or without x-rays have been performed on you to minimize these risks to yourself. Chiropractic is considered to be one of the safest and most effective forms of therapy for neck conditions. The Chiropractor may also scan your feet for custom made orthotics to determine if you may benefit from them. The fee for this scan is included with your New Patient Examination. The Chiropractor may also suggest other treatments, including: Low Level Lasers, Shockwave Therapy & Kinesio Taping in addition to Chiropractic adjustments. All of the services are none invasive and promote faster healing and pain relief. As Chiropractors we do not claim to treat any specific diseases or ailments. (This includes: High Blood Pressure, Diabetes, ADHD e.c.t). We simply work with the spine to attain optimal alignment and nervous system function. If you have any questions about this, please ask your Chiropractor.

 

PRIVACY POLICY:

In accordance with the privacy act effective January 2004, we must ask for your informed consent. This means we want you to understand what we do with personal information. Your signature below allows us to obtain this information to open a confidential file for you. This is the only reason we collect your personal information. I understand that to provide me with Chiropractic goods and services, Lifetime Wellness Center will collect some personal information about me (e.g.: telephone number, birth date, address, etc.).

 

We use and disclose your personal health information to:

·          treat and care for you,

·          plan, administer and manage our internal operations,

·          conduct quality improvement activities (such as sending patient satisfaction surveys)

·          teach,

·          compile statistics,

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 17 Oct 2017