100 % Tallahassee
1950 Thomasville Road, Suite E
Tallahassee, FL 32303
(850) 536-6789
drwill@100percentchiropractic.com
100 % Tallahassee
1950 Thomasville Road, Suite E
Tallahassee, FL 32303
(850) 536-6789
drwill@100percentchiropractic.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?
100 % Tallahassee
1950 Thomasville Road, Suite E
Tallahassee, FL 32303
(850) 536-6789
drwill@100percentchiropractic.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
100 % Tallahassee
1950 Thomasville Road, Suite E
Tallahassee, FL 32303
(850) 536-6789
drwill@100percentchiropractic.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
100 % Tallahassee
1950 Thomasville Road, Suite E
Tallahassee, FL 32303
(850) 536-6789
drwill@100percentchiropractic.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
100 % Tallahassee
1950 Thomasville Road, Suite E
Tallahassee, FL 32303
(850) 536-6789
drwill@100percentchiropractic.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:

100 % Tallahassee
1950 Thomasville Road, Suite E
Tallahassee, FL 32303
(850) 536-6789
drwill@100percentchiropractic.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
100 % Tallahassee
1950 Thomasville Road, Suite E
Tallahassee, FL 32303
(850) 536-6789
drwill@100percentchiropractic.com
Please read the following carefully before signing.

Terms of Acceptance

 

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. The process if often referred to as “ informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risk associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.

 

We may conduct some diagnostic or examination procedures if indicated. Any examinations or test conducted will be carefully performed but may be uncomfortable.

 

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment includes restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

 

It is important that you understand, as with all heath care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscles spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs, and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as and “arterial dissections” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease process, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Stokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.

 

Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke.

 

The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users.

 

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self- administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

 

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendations to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care form all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

 

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