Infinite Health Chiropractic
222 E. Blackstock Rd. Suite D
SPARTANBURG, SC 29301
(864) 574-8881
lsrhodeschiro05@gmail.com

Welcome to Infinite Health Chiropractic "Restoring Health Today for an Optimal Tomorrow!"

 

Business Hours: 

Monday & Wednesday: 9:00am-12:00pm, 2:00pm-6:00pm

Tuesday: 12:00pm-6:30pm

Thursday: 12:00pm-5:00pm

 

*Please note an appointment is required for new patients. Call 864-574-8881 for scheduling

Infinite Health Chiropractic
222 E. Blackstock Rd. Suite D
SPARTANBURG, SC 29301
(864) 574-8881
lsrhodeschiro05@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?
Infinite Health Chiropractic
222 E. Blackstock Rd. Suite D
SPARTANBURG, SC 29301
(864) 574-8881
lsrhodeschiro05@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
Infinite Health Chiropractic
222 E. Blackstock Rd. Suite D
SPARTANBURG, SC 29301
(864) 574-8881
lsrhodeschiro05@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
Infinite Health Chiropractic
222 E. Blackstock Rd. Suite D
SPARTANBURG, SC 29301
(864) 574-8881
lsrhodeschiro05@gmail.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Infinite Health Chiropractic
222 E. Blackstock Rd. Suite D
SPARTANBURG, SC 29301
(864) 574-8881
lsrhodeschiro05@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:

Infinite Health Chiropractic
222 E. Blackstock Rd. Suite D
SPARTANBURG, SC 29301
(864) 574-8881
lsrhodeschiro05@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
Infinite Health Chiropractic
222 E. Blackstock Rd. Suite D
SPARTANBURG, SC 29301
(864) 574-8881
lsrhodeschiro05@gmail.com
Please read the following carefully before signing.

 

Health—you and your family’s—is the most valuable asset in the world. Chiropractic brings ease and peace to your body and life. The adjustments restore and enhance the full function and communication within your nervous system and body as a whole—from the brain to every organ, tissue, and cell. As you receive chiropractic adjustments and personally strive toward a healthier lifestyle, your Innate Intelligence will express your fullest potential for healing and life. Here at Infinite Health Chiropractic, we do not chase symptoms or treat diseases; we offer healing through chiropractic. This healing includes taking responsibility for your health and meeting your financial obligations. Chiropractic is neither atreatment nor cure of disease. I clearly understand and agree to the above statements, and I accept chiropractic based on the previously stated information. My signature below shall serve as consent for services; furthermore, this release of information shall remain in effect until terminated by me in writing.

 

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 14 Dec 2019