PANGEA CHIROPRACTIC PEDIATRIC HISTORY FORM
WHO MAY WE THANK FOR REFERRING YOU?
Confidential Patient Information
Today's Date / /
May we text appointment reminders Yes No
Childs Name Date of Birth / / Age:
Birth Height: Birth Weight: Current Height: Current Weight:
Address City State Zip
Mother’s Name: Father’s Name:
Mother’s Mobile Father’s Mobile
Pediatrician/Family MD City/State Who is responsible for this bill?
Purpose of this visit: Wellness Check-up Injury or Accident Other What health condition(s) bring your child to be evaluated by a chiropractor at Pangea:
If your child is experiencing Pain/Discomfort please identify where and for how long:
When did the Problem first begin? Date / / Unknown Gradual Sudden
Ever had this problem before? No Yes If yes, when?
Any bowel or bladder problems since thisproblem began? If yes, describe:
Have you seen any other doctors for this problem? No Yes If yes, who?
How long ago? Days Weeks Months Years
What were the results of past treatment?
How is this problem NOW? Rapidly Improving Improving Slowly About the Same
Gradually Worsening On & Off Unsure
Please list any drugs/medications/vitamins/herbs other that your child has or is taking:
Has your child ever sustained significant injury playing organized sports? No Yes If yes; pleaseexplain:
Has your child ever sustained an injury in anauto accident? No Yes If yes; please explain:
Has your child suffered a concussion? No Yes If yes; how many
Has your child been vaccinated? No Yes ( up to date Delayed)
List any reactions from vaccines:
Please tell us about your pregnancy
If yes explain: _
If yes explain: _
3. Did mother drink?
If yes explain:
4. Did mother exercise?
If yes explain:
5. Was mother ill?
If yes explain:
6. Any ultrasounds?
If yes explain
Please list any notable episodes of mental or physical stress during your pregnancy:
Vaginal Birth Scheduled C-Section Emergency C-Section (At how many weeks was yourchild born? )
Home Birth Birthing Center Hospital Please check any applicable interventions:
Breech Induction Pain Meds Epidural Episiotomy Vacuum Forceps Please list any concerns or notable remarks about your child’s birth/delivery
Is/was your child breastfed? Yes No If yes, howlong?
Did they ever use formula? Yes No If yes, what age?
Did your child have any delays or challenges in any of the following
Difficulty breastfeeding Yes No What type?
Respond to sound
Holding head up
If yes explain
Has your child received any antibiotics? Yes No If yes, what age? How long?
How many hours per day watching TV, Computer, tablet or phone?
How would you describe your child’s diet? Mostly whole, organic foods Pretty average Highly processed
My child’s diet includes: gluten Dairy Processed sugars
Acknowledgement & Consent:
Parent Signature: Date:
PANGEA CHIROPRACTIC PEDIATRIC CONDITIONS
Check all that apply:
Headaches Orthopedic Problems Digestive Disorders Behavioral Problems
Dizziness Neck Problems Poor Appetite ADD/ADHD
Fainting Arm Problems Stomach Aches Ruptures/Hernia
Seizures/Convulsions Leg Problems Reflux Muscle Pain
Heart Trouble Joint Problems Constipation Growing Pains
Chronic Earaches Backaches Diarrhea Asthma
Sinus Trouble Poor Posture Hypertension Walking Trouble
Scoliosis Anemia Colds/Flu Sleeping Problems
Bed Wetting Colic Broken Bones Fall off swing
Fall in baby walker Fall from bed or couch Fall from crib Fall down stairs
Fall off bicycle Fall from high chair Fall off slide Fall off skateboard/skates
Fall from changing table Fall off monkey bars
Allergies to evvironment
Allergies to food
I understand that I am directly and fully responsible to Pangea Chiropractic for all fees associated with chiropractic care my child receives.
The risks associated with exposure to ionization and spinal adjustments have been explained to me to my complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful consideration, I do hereby request and authorize imaging studies and chiropractic adjustments for the benefit of my minor child for whom I have the legal right to select and authorize health care services on behalf of.
Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify this office.
Parent or Legal Guardian’s Signature Date
Doctor’s Signature Date
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic X-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future work at the clinic or office listed below or any other office or clinic.
I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.
I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Patient Signature Date
Pangea Chiropractic 409 NE Greenwood Ave. Ste#120 Bend, OR 97701
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
1. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment : We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third Party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements
of Section 164.500. Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken on action in reliance on the use or disclosure indicated in the authorization. Your Rights. Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before January1st 2014
We are required by law to maintain the privacy of and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our FHPAA Compliance Officer in person or by phone at our Main Phone Number
Signature below is only acknowledgement that you have received this Notice of our Privacy Practices: Print
Name: Signature Date