100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com

Introduction to the Office

 
Let us extend a warm and personal welcome to you and your family on behalf of the 100% team!  We want to provide you with the finest health care and we’ll offer you many informative and entertaining educational opportunities.

First, you will want to make informed decisions regarding your family's health.  During the course of your child's care you will be presented with several choices that will affect your ability to reach your individual health objectives.

Second, this information will be useful in making decisions about your child's health for the rest of his/her life.

To begin this process, here are a few important terms and procedures as you begin care:

On your child's first visit we will gather information about him/her through our Initial Discovery (examination and consultation).  There will be someone here to assist you in each step along the way.  If you’re not sure about what we need, just ask.  Nothing will be done
without your consent and full understanding.


We will be giving you information and clinical data in the form of literature, personal and media presentations.  These are designed to help you understand your own case and the procedures you’ll experience in this office.  Everything is brief and to the point.  It is recommended that you read the material and keep it together for reference during the course of your care.

Just as we need to know about your child, you should know about us.  Chiropractic education currently consists of four years of pre-Chiropractic college education in the biological sciences, followed by another five years of Chiropractic education and clinical internship.  Then we are required to attend many hours of post-graduate education each year for license renewal.  On top of this, our office is frequently involved in various seminars to keep abreast of the latest information.

We are excited to show you how chiropractic can change your family members lives!  Let's get started!

 

Team 100%

 

100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
Please read the following carefully before signing.

When a person seeks Chiropractic care and we accept a person for such care it is essential for both to be working towards the same objective.  Chiropractic has only one goal.  It is important that each person understand both the objective and the method that will be used to attain it.  This will prevent confusion.

Adjustment:  A specific application of forces to facilitate the body’s correction of the vertebral subluxation.  Our chiropractic method of correction is by specific adjustments of 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 vertebrae in the spine resulting in nerve dysfunction, resulting in the lessening of the body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease.  Our focus in this office is the vertebral subluxation.  However, if we encounter non-chiropractic or unusual findings we will advise you.  If you desire advice, diagnoses or treatment for those findings we recommend that you seek another healthcare 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 locate, analyze and correct vertebral subluxation by specific adjustments.

I have read and fully understand the above statements.  All questions regarding the chiropractor's objectives to my care in this office have been answered to my complete satisfaction.  I therefore accept care on this basis.


Consent to Evaluate and Adjust a Minor:  I, being the parent or legal guardian of patient, have read and fully understand the above Terms of Acceptance and hereby grant permission for my child to receive Chiropractic care.

 

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 25 Jul 2017