University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com

Hello & Welcome from Dr. Sandra Childers

 

We are honored that you have given us the opportunity to help your child be as healthly as possible.  We want to do what we can to help you & your family reach optimal health as soon as possible.

 

Please take the short time to fill out these health questionaires as thoroughly as possible. After 20+ years in practice together we have found that the more thorough we are at the begining the best chance we have to help you baby's body heal faster.  Thanks again for your trust in me.

 

After completing each section click the "Next" button at the bottom of the page.  Once completed your information with be automatically sent to our secure computer server/software.  We will not share any of your confidential inforamtion with anyone or any insurance company (life or health, etc) without your expressed permission.

 

Yours in Health

 

Dr. Sandra

University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.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?
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.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
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.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
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.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:

University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.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
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
Please read the following carefully before signing.

I hereby certify that I have read & understand the information above to the best of my knowledge.  The previous questions have been answered and as accurately as possible.  I understand that providing incorrect information could pose a danger to my health.

 

I authorize Dr. Sandra Childers to release any medical information to a 3rd party / health insurance company if I wish to have Dr. Childers file my insurance.

 

I authorize my nsurance company to pay Dr Sandra Childers directly & I understand my insurance may pay less than my actual bill for services rendered at University Chiropractic.  And if this happens I agree to be responsible for payment of all services rendered on behalf of my dependants.

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 26 Jun 2017