Pediatric History Form

Dear New Patient,

It is a pleasure to welcome you to our family of happy and healthy chiropractic patients. Please let us know if there is any way we can make you and your family feel more comfortable. To help us serve you better, please complete the following information. We look forward to working with you to build better health for your family.

Patient Name:
Social Security:
Address: City: State: Zip:
Home Phone:
Birth Date:
Work Phone:
Sex:
Weight:
Height:
Referred By:
Names of Parents/Guardians:


Purpose for contacting us?


Other Doctors Seen for this condition: Yes No
Doctors' Names and Prior Treatments:
Other Health Problems?
Check any of the following conditions your child has suffered from during the past six months: Ear Infections Asthma/Allergies Colic Scoliosis Digestive Problems Bed Wetting Seizures ADHD Car Accident Chronic Colds Recurring Fevers Temper Tantrums Headaches Growing/Back Pains Other
Family History:
Previous Chiropractor:
Date of Last Visit: Reason:
Name of Pediatrician:
Date of Last Visit: Reason:
Are You Satisfied with the Care Your Child has Recieved There? Yes No
Number of Doses of Antibiotics Your Child has Taken:
Within the Past Six Months:
Total During His/Her Lifetime:
List:

Vaccination History:



Prenatal History:
Name of Obstetrician/Midwife:
Complications During Pregnancy? Yes No List:
Ultrasounds During Pregnancy? Yes No Number:
Medications During Pregnancy/Dellivery? Yes No List:
Cigarette/Alcohol Use During Pregnancy: Yes No
Location of Birth: Hospital Birthing Center Home
Birth Intervention: Forceps Vacuum Extraction Ceasarian Section None
Was the Intervention Emergency or Planned? Emergency Planned No intervention
Complications During Delivery? Yes No List:
Birth Weight:
Birth Length:
APGAR Scores: ,


Feeding History:
Breast Fed? Yes No How Long:
Formula Fed? Yes No How Long:
Introduced to Solids at: Months
Cow's Milk at: Months
Food/Juice Allergies or Intolerances: Yes No
List:



Developmental History:
During the following times your child's spine is most vulnerable to stress and should routinely be checked by a doctor of chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference). At what age was your child able to:
Respond to sound?
Respond to visual stimuli?
Hold his/her head up?
Sit up?
Cross crawl?
Stand alone?

According to the National Saftey Council, approximately 50% of children fall head first from a high place during their first year of life (i.e., a bed, changing table, down stairs, etc.). Was this the case with your child? Yes No
Is/has your child been involved in any high impact or contact type sports (i.e., Soccer, Football, Gymnastics, Baseball, Cheerleading, Martial Arts, etc.)?
Yes No

List:

Has your child ever been involved in a car accident? Yes No
List:


Has your child been seen on an emergency basis? Yes No
List:


Other traumas not described above? Yes No
List:


Prior surgery? Yes No
List:


Menarche? Yes No Age:


Childhood Diseases
Chicken Pox? Yes No Age:
Rubella? Yes No Age:
Rubeola? Yes No Age:
Mumps? Yes No Age:
Whooping cough? Yes No Age:
Other? Yes No Age:

WE ARE HERE TO SERVE YOU, AND ENCOURAGE YOU TO ASK QUESTIONS.
YOUR PARTICIPATION IS VITAL AND WILL HELP DETERMINE YOUR RESULTS.
AUTHORIZATION FOR CARE OF MINOR

I hereby authorize this office and its Doctors to administer care to my Son/Daughter as they deem necessary. I can understand and agree that I am personally responsible for payment of all fees charged by this office.
Name of Insurance Company: Policy #:
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Money Back Guarantee


We can not guarantee your results but we want you to be satisfied that we will do everything we can to help you. If within three visits you become unhappy with your decision to consult our office, we will refund the money you paid us and make other care recommendations. After the third visit however, there will be no refunds.

I hereby certify that I understand and agree to this policy.



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ROSSI FAMILY CHIROPRACTIC
FRED ROSSI, JR.,DC

1027 "A" VALLEY ROAD
STIRLING, NJ 07980
908-903-9400


TERMS OF ACCEPTANCE


When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working for the same objective.
Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: The adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Out chiropractic method of correction is by specific adjustments of the spine.
Health: The state of optimal physical, mental and social well being, not merely the absence of disease of infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.

We do not offer diagnosis or treat any disease. We only offer to diagnosis either vertebral subluxations or neuro-musculoskeletal conditions. However, during the course of a chiropractic spinal examination we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care 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 eliminate major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. However, we may use other procedures to help your body hold the adjustments.

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Rossi Family Chiropractic HIPPA Compliant Form
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
In the course of your care as a patient at Rossi Family Chiropractic we may use or disclose personal and health related information about you in the following ways: *Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
*Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, and HMO, a PPO, or your employer, if they are or maybe responsible for the payment of services provided to you.
*Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the agreement of this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other related information, a message may be left on your answering machine or with a person in your household. You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
*If we provide health care services to you in an emergency. *If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so. *If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
*If we are ordered by the courts or another appropriate agency.
You have a right to receive an accounting of any such disclosures made by this office.
Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date.
Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.
We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a specific form please advise us in writing as to your preference.
We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect.
We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.
If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaints to: Dr. Fred Rossi. ________________________________________________________________________________________________________________________
If you would like further information about our privacy policies and practices please contact: Dr. Fred Rossi. ________________________________________________________________________________________________________________________ You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever. Your authorization is requested for purposes of delivering your care in an open-adjusting or open-door adjusting environment as described in the office's privacy notice. In the course of your care in either of these environments routine details of your condition and care may be disclosed to other patients or staff in the approximate vicinity of where your care is being delivered. We cannot assure that any of the details of your care will be addressed and considered as confidential by other patients.
We are requesting your authorization in this regard to assure that you are fully informed and in agreement with the method and circumstances in which we deliver chiropractic care. Your care will not be conditioned on your agreement to this authorization. You have the right not to sign this authorization and you also have the right to revoke this authorization at a later date if that is your wish.
If you wish to revoke this authorization at some time in the future please advise us accordingly in writing.
If you agree to this authorization a copy will be maintained by this office and a copy will be provided to you.

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