Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com

Hello!

 

Welcome to Family First Chiropractic.  We have been serving the Greater Omaha Area since July 2007; helping individuals and families of all ages reach their true health potential through the power of specific Chiropractic care.  Someone or something compelled you to reach out for a checkup for your child with us, and know that we take that choice very seriously.  You can count on us to provide you great service from our amazing team the moment you enter our office for your first visit.  You can count on us to truly care about your child's current state of health and helping them with whatever we can to get it to where you want it to be.  Given your child is a candidate for chiropractic care after thier exam, you can count on us to provide your child elite level chiropractic care utilizing the Gonstead Method by a great team of doctors.  We take great pride in the service we provide, and want you to know we look forward to meeting you and your child, and discover how we can help.

In Health, Dr. Joel Marley (Clinic Director)

Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@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?
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@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
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@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
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@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:

Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@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
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
Please read the following carefully before signing.

It is important that our patients and we have the same health objectives concerning chiropractic care. Regardless of what a disease or condition is called we do not offer to treat it. Our only practice objective is to eliminate a major interference to the expression of the bodys internal wisdom and power. Our only method is specific adjusting to correct vertebral subluxations; which interfere with the bodys internal wisdom and power. We believe that the greatest Doctor is the one already inside of each of our patients and we only help to maximize that inherent healing power, without using drugs or surgery. Your signature verifies that the information given in this form is complete and correct and that you accept, if eligible, chiropractic care for your child on this basis.

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 14 Dec 2018