Child Initial Assessment 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. *

I agree with submitting the form below via email

Please select the option above if you would like to submit this online form directly to Dr. Muller's email address. If you prefer to download a PDF version of this form, please click here to download a copy. Complete the form and bring a printed version with you on your initial appointment.

IMPORTANT: We will use the minimum necessary amount of protected health information in any communication and will not send you unnecessary emails and/or TXT messages. By providing your consent below, we will be able to send you reminders for upcoming appointments, receipts and occasional notifications. *

I consent to receiving appointment reminders, receipts, and occasional notifications via email and/or TXT messages. I understand I can withdraw my consent at any time.

My Email Address is *

Please use an email address of the child's parent or legal guardian

Patient Full Name *

Date of Birth

Age

Gender

Parent(s)/Guardian(s) *

Address *

Home Phone # *

Mobile Phone #

Has your child ever been treated by a chiropractor? *

Date of your child's last chiropractic visit? (if applicable)

Name(s) of previous chiropractor(s) (if applicable)

Reason for your child's last chiropractic visit (if applicable)

Paediatrician *

Date of last Paediatrician visit?

Reason for last Paediatrician visit

Who may we thank for referring you and your child to our office?

YOUR CHILD'S HEALTH PROFILE

Misaligned vertebrae, pinched nerves in the spine, and/or unbalanced nerve system can affect the child’s health.

What is your purpose for contacting us? *

Number of doses of antibiotics taken in the past 6 months and reason

Number of doses of antibiotics taken in lifetime and reason

Number of doses of prescription medications taken in the past 6 months and reason

Number of doses of prescription medications taken in lifetime and reason

List of current medication and reason

Vaccination History

Family History of Disease/Illness

PRENATAL AND BIRTH HISTORY

Birth trauma can produce some of the first spinal problems in the delicate spine of a newborn

Name of Midwife or Obstetrician

Any complications during your pregnancy?

If you selected Yes, please add details

Premature baby?

If you selected Yes, how early?

Ultrasounds during pregnancy?

If you selected Yes, how many?

Other exams done

Did you smoke and/or consume alcohol during your pregnancy?

Were there any complications during your delivery?

If you selected Yes, please add details

Birth Weight

Birth Length

APGAR at birth

APGAR at 5minutes

FEEDING HISTORY

If you have any concern or difficulty with breastfeeding, please let us know and a referral to a specialist can be arranged

Was your child breastfed?

Was your child formula fed?

If Yes, for how long?

Any problems with breastfeeding?

Type/Brand

Age when started solid food

Type of food

Age when started cow’s milk

Does your child have any food or drink allergies/intolerances?

If you selected Yes, please specify

DEVELOPMENTAL HISTORY

Many childhood falls can produce long-term spinal misalignments that may surface many years later in life

Has your child ever had a major fall (change table, crib/bed, tree) or a car accident?

If you selected Yes, please add details and dates

Has your child ever had a sports injury or been involved in a high impact or contact sport (soccer, football, hockey, gymnastics, cheerleading, martial arts)?

If you selected Yes, please add details and dates

Has your child ever had surgery or been seen on an emergency basis?

If you selected Yes, please add details and dates

Female Patients: Menarche?

Is the period regular?

Age of first period

Any pain/discomfort?

EXTENDED HEALTH CARE INSURANCE - DIRECT BILLING

Direct billing may be available to you. If you have Extended Health Care Insurance available, please provide the information below.

Name of Insurance

Policy Number

Member ID

Name of insured member

Relationship to the child

Date of birth of insured member

AUTHORIZATION FOR CARE OF A MINOR: I hereby authorize Dr. Danny Muller to evaluate and administer care to my child as she deems necessary. I clearly understand and agree that I am personally responsible for payment of my child’s fees. I understand my obligation to give further notice if the appointment needs to be rescheduled or cancelled, which should be done at least 24 hours prior to my (child's) scheduled appointment. If prior notification is not given, a missed appointment fee is applied (the correspondent fee of the missed treatment). If you miss or are not able to attend your appointment, Dr. Muller will offer a virtual appointment, where recommendations on exercises and/or stretches will be sent to you through video call, phone call, and/or email. *

Please select to agree *

I agree with the terms above

Phone