Pediatric Health Profile

Child's First Name *

Child's Last Name *

Child's Nickname

Date of birth *

Age *

Male

Female

Number of siblings

Pediatrician *

Address *

City *

Province *

Postal code *

Home Phone

Work Phone

Cellphone No. *

Email *

Preferred Contact Method

Home Phone

Work Phone

Cell Phone

Who may we thank for referring you to us? *

Would you like appointment reminders sent via Email?

Yes

Statements sent to you via Email?

Yes

HEALTH CONCERN(S)

Briefly describe what brings you into our office today (if more than one, please list them in order of importance) *

It has been

getting better

worse

the same

How does this effect your child? *

When is the problem worse/better?

Name(s) and approximately when

What was the diagnosis and treatment provided

CHILD’S STRESS PROFILE

Physical:

Sports injuries, slips, falls, car accidents *

Emotional Stresses (Rate high or low)

School *

Family/Relationship *

Other stresses

Nutritional Chemical Stresses (1=poor, 10=excellent)

Please rate each of the topics below on a scale of 1 (poor) to 10 (excellent).

Exercise *

Sleep *

Water *

Proteins

Healthy Fats

Fruits/Vegetables *

Is your child’s diet high in

Sugar

Unhealthy snacks

Soda

Processed foods

Check those taken regularly

Omega 3 Fish Oils

Vit D

Probiotics

Other

Other Supplements

MOTHER’S HEALTH HISTORY

If there are any other health related issues that concern you regarding your child, or anything else you would like to let us know, please do so here

Consent To Care

Our Chiropractic practitioners generally employs “tonal” instrument assisted Chiropractic techniques that do not involve rotational “manipulation” of the neck. These techniques allow the Chiropractic care provided to you to have a profound effect on your spine and nerve system through gentle taps without the use of forceful movements.

In general, Chiropractic care is safer than taking anti-inflammatories, pain killers, and virtually any other medication. There has been some concern about injury to the vertebral artery with extreme rotational movements of the neck being associated with stroke on rare occasion, however, research and scientific evidence have not established a cause and effect relationship between Chiropractic treatment and the occurrence of stroke. At A Natural Path to Health we employs non-manipulative neck adjusting techniques, except in the event that it is agreed upon by the patient and doctor to use other adjusting techniques, because it makes clinical sense to do so. As with any manual therapy there is always the possibility of soft tissue strain or irritation, minor discomfort and short term aggravation of symptoms as nerve function improves, functionality changes and tissues balance.

Chiropractors do not diagnose disease or disease processes. His focus is on detecting, locating and correcting Vertebral Subluxation (spinal neural malfunction) in as gentle a manner as possible, to enable your body to function and heal to the best of its’ ability.

I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my Chiropractor the nature and purpose of Chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this Consent.

I will inform the Doctor of any changes in health status that occur between visits.

I understand that all fees for services rendered are due at the time of service and cannot be deferred to a later date. Please note many of our patients prefer to leave a credit card number on file with us which we bill according to your express instructions.

By continuing with this form, I acknowledge the above statements to be true.

Basic Fee Schedule:

Initial Chiro Exam (New patients and patients not seen in 18 months): $199

Regular chiropractic adjustment: $55- $65

Wellness care adjustment: $50

Reassessment for patients currently under care: $139

Reassessment (Patients who have not been under care 5 – 18 months): $149

Guardian Initials

On behalf of

I have read the above & I hereby authorize Dr. Weitz and Dr. Shach, or such substitute as they may designate, to perform a complete spinal-neural examination including Insight Scans, and I consent to Chiropractic care recommended or said substitute, including spinal adjustment. I intend this consent to apply to all present and future care.

Dated this day of

Guardian Name

Guardian Signature

Clear