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631-244-0300
info@pojerofamilychiropractic.com
Home
Services
Adult Chiropractic Care
Kids Chiropractic Care
About Us
Dr. John & Dr. Gaby
Testimonials
Gallery
Subluxation
Subluxation
Spinal Degeneration
Forms
Welcome Form
Patient Consent Form
Personal Health History Form
Child Health History Form
No Fault Form
Terms Of Acceptance Form
HIPAA Form
Contact Us
Please enable JavaScript in your browser to complete this form.
Child's Name
Date Of Birth
Age
Address
City/State/Zip
Parent's Email
Home Phone #
Parents Cell Phone #
Mother's Name
Father's Name
Names & Ages of Siblings
Reasons for Consulting Our Office
Referred By
Previous Chiropractic Care?
Previous Chiropractic Care?
Yes
No
With Whom?
How Long Was Care Received?
Reason for Stopping Care?
Background Information
CHECK OFF APPROPRIATELY
Birth Place:
Home
Birth Center
Hospital
Type:
Vaginal
C-Section
Procedures:
Forceps
Vacuum Extraction
Was Delivery Long?
Yes
No
Was Delivery Difficult?
Yes
No
Labor Induced?
Yes
No
Epidural?
Yes
No
Pain Medication?
Yes
No
Was Baby Breech/in Utero-Constraint?
Yes
No
Was Baby Breast Fed?
Yes
No
How Long?
Which sports does/did your child participate in:
Soccer
Football
Gymnastics
Cheerleading
Karate
Basketball
Dance
Lacrosse
Other
If Other Please Describe:
According to the National Safety Council, approximately 54% of infants fall head first from a high place (bed, changing table, etc.) during their first year of life. Has this happened to your child?
Yes
No
Please Explain
Comments:
List any other fall or accidents:
Check any of the following your child has suffered from:
Ear Infections
Scoliosis
Seizures
Chronic Colds
Asthma/Allergies
Digestive Problems
Headaches
A.D.D.
A.D.H.D.
Recurring Fevers
Growing/Back Pains
Colic
Bed Wetting
Constipation
Head Banging
Other ailments your child has suffered from:
Medications
How many rounds of antibiotics has your child taken in last 6 months?
Lifetime?
Present Prescription Drugs
Past Prescription Drugs
Over the Counter Drugs (Tylenol, cough syrups, laxatives, etc.)
FINANCIAL INFORMATION
Who is responsible for this account?
Relationship?
Date Of Birth
Employer
What method of payment will you be using?
Insurance
Cash
Check
Other
Insurance Company
Policy/ID#
Address
Phone #
AUTHORIZATION FOR CARE OF A MINOR
I hereby authorize:
and whomever they may designate to administer care to my son/daughter:
Signature
Clear Signature
Relationship to minor:
Date:
Witnessed:
(In office use only)
Email
Submit
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Contact Us:
Pojero Family Chiropractic
153 Main Street, Sayville, NY 11782
631-244-0300
info@PojeroFamilyChiropractic.com
www.PojeroFamilyChiropractic.com
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