Hoffman Family Chiropractic

Hoffman Family Chiropractic

Dr. Myra D. Hoffman

8727 Shoal Creek Blvd, Austin, TX 78757

512-346-5164

Pediatric Intake Form

PATIENT NAME______DATE OF BIRTH ______

SEX MALE OR FEMALE WEIGHT______HEIGHT______# OF SIBLINGS______

ADDRESS______CITY ______STATE_____ZIP______

PURPOSE OF THIS VISIT______

WHO REFERRED YOU TO OUR OFFICE ______

MOTHER’S NAME______ PHONE______

FATHER’S NAME______PHONE______

INFORMED CONSENT TO TREAT

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including

various modes of physical therapy on me (or the patient named above for whom I am legally responsible)

by the doctor of chiropractic named above and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named above, including those working at the clinic or office listed above or any other office or clinic. I have had an opportunity to discuss with the doctor of chiropractic named above and /or with the office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to: fractures, disc injuries, strokes, dislocations, sprains, soreness, and physical therapy burns. I understand and comprehend all such risks and complications. I, by my signature below, confirm and accept care and therefore consent to and agree to those treatments deemed by my doctor to be in my best interest. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.

Patient’s Name ______

Signature of Parent ______Date______

ACKNOWLEDGEMENT OF HIPPA NOTICE

I acknowledge that the Notice of Privacy Practices for Hoffman Family Chiropractic has been made available to me. I understand that I have the right to review the Notice prior to signing this document. The Notice describes the types of use and disclosures of my protected health information that will occur in my treatment, payment of my bills, and/or the performance of healthcare operations at Hoffman Family Chiropractic. Hoffman Family Chiropractic reserves the right to change the privacy practices that are described in the Notice. I understand that I may obtain a revised Notice at www.hoffmanhealth.com or by calling and requesting a copy by mail, or

by picking one up at their offices.

Patient’s Name ______

Signature of Parent ______Date______

PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED

CHIEF COMPLAINT and CONFIDENTIAL PATIENT HISTORY

1. Describe what has brought you to our office today: ______

______

When did symptoms begin: ______Last occurrence: ______

Aggravation/relief factors______/______

Are symptoms changing? Better/Worse? Does pain interfere with daily activities? ______

2. This condition is the result of: Birth/Auto Accident/Fall/Trampoline/Sports/Other______

3. Who else has child seen for this condition?

Provider Name Phone Diagnosis Treatment

4. What medications has child taken including over the counter drugs and vitamins?

Name of Drug Dosage Diagnosis Date Started

5. Has child had any previous surgeries or hospitalizations?

Date Diagnosis Procedure Provider

6. Does child suffer from any of the following?

__ Allergies

__ Anemia

__ Arm Problems

__ Asthma

__ Austism

__ Autoimmune Disease

__ Backaches

__ Bed Wetting

__ Broken Bones

__ Chicken Pox

__ Clavicle Problems

__ Colds/Flu

__ Congenital Anomalies

__ Constipation

__ Cranial Issues

__ Crawling Problems

__ Diabetes

__ Diarrhea

__ Digestive Problems

__ Dizziness

__ Ear Infections

__ Eczema

__ Eye Problems

__ Fainting

__ Fifths Disease

__ Gas

__ Growing Pains

__ Hand Foot and Mouth

__ Headaches

__ Heart Problems

__ Hyperactivity

__ Hypertonia

__ Hypotonia

__ Latch Problems

__ Leg Problems

__ Lip Tie

__ Measles

__ Mumps

__ Neck Restrictions

__ Nursemaid’s Elbow

__ Poor Appetite

__ Reflux

__ Sinus Problems

__ Sitting Problems

__ Sleep Problems

__ Strep Throat

__ TMJ Restrictions

__ Toe Walking

__ Torticolis

__ Tongue Tie

__ Walking Problems

__ Whooping Cough

Signature: ______Date: ______