Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com

NEW CHILD INTAKE

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*Please fill out the following pages to the best of your ability.  This information will help us to give you the best and most effecient chiropractic care.  If you have any question please do not hesitate to ask us.  Thank you!

* If your child is over the age of 2- you can skip the questions on page 2. Just hit the NEXT button at the bottom of the page. 

*If you do not know the answers to some questions please leave them blank and move on.  

When you are ready to begin, just hit the NEXT button below. 

Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@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?
Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@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
Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@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
Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@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:

Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@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
Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
Please read the following carefully before signing.

Consent to Initiate Care

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Starting care in our office will consist of at least 2 appointments: Your initial visit and a follow up report of findings.  More care may be suggested at your Report of Findings depending on your case. 

Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. 

 

ADJUSTMENT: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxations. At Steinke Family Chiropractic the main method of adjusting is gentle and specific using an instrument called the Integrator.  Our specific adjusting style is call Torque Release Technique. Our chiropractic method of correction is by specific adjustments to the spine. 

 

HEALTH: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. 

 

VERTEBRAL SUBLUXATION: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential. 

 

We do not offer to diagnose or treat any disease or condition other than vertebral subluxations. However, if during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual finding, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. 

 OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. 

I acknowledge that I have read and fully understand the above statements. I give consent to Steinke Family Chiropractic to move forward with a chiropractic evaluation, any needed Radiologic Examinations, and any needed chiropractic adjustments at this time. I understand that I am not obligated to move forward with any further care unless I agree to such care at my report of findings.

Cost of Nerve Assessment/Initial Evaluation-      $50

Cost of X-rays-                                              $50 per set (typically two sets are taken)

Total Maximum Cost per person for Initial Evaluation:     $150 

 

Notice of Privacy Practices Acknowledgement

I understand that I have certain rights of privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996. (HIPAA). I understand that this information can and will be used to:

1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who

may be involved in that treatment directly and indirectly.

2. Obtain payment from third-party payers.

 

* Please read and agree to the terms
Relationship to patient
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Today's Date: 22 Oct 2019