Initial Child & Adolescent Questionnaire

Full Name

Age

Date of birth

Address

City

Postal code

Mother's name

Father's name

Cell Phone

Grade

Sports and hobbies

How did you hear about us? Who may we thank for referring you?

Current pediatrician

City of Pediatrician

Have you or your child ever received chiropractic care?

Name of D.C.

The information I have provided on this form, is true and accurate to the best of my knowledge. I give Dr. Michael P. Griffin permission to render care today. This initial visit includes a health history/consultation, chiropractic exam/evaluation. I also give my consent to have the doctor order any x-rays that he deems appropriate, and any initial care that is determined to be clinically necessary and mutually agreed upon.

Signature of Parent (for minor):

Clear

Today’s Date