Application for Care - Pediatrics - Juergens Chiropractic

Application for Care – Pediatrics

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CHILD'S DEMOGRAPHICS

Child's Name*

First Last

Date of Birth

Month

Day

Year

Age

Gender

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Mother's Name

First Last

Same address as child?

Mobile Phone Number

If No, please list address:

Street Address City State / Province / Region ZIP / Postal Code Country

Father's Name

First Last

Same address as child?

Mobile Phone Number

If No, please list address:

Street Address City State / Province / Region ZIP / Postal Code Country

Who is responsible for the bill?

Birth Height

Current Height

Birth Weight

Current Weight

Pediatrician/Family MD

City/State

Last Visit

Reasons for Visit

CHILD'S PROBLEMS

Purpose of this visit:

If child is in Pain/Discomfort, identify where and for how long:

When did the problem first begin?

Other

Has the child had this problem previously?

If Yes, when?

Have you seen another doctor(s) for this problem?

If Yes, please provide the doctor's name and when?

What were results of last treatment?

How is the problem now?

Rapidly improving

Slowly improving

About the same

Worse

List any medications taken for this problem:

Has child sustained an injury playing sports?

If Yes, what injury?

Has child sustained an auto accident injury?

If Yes, what injury?

Allergies

HAS CHILD SUFFERED FROM

Check all that apply.

Select

Headache

Dizziness

Fainting

Seisure/Convulsions

Heart Trouble

Neck Index

This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.

Pain Intensity

I have no pain at the moment

The pain is very mild at the moment.

The pain comes and goes and is moderate.

The pain is fairly severe at the moment.

The pain is very severe at the moment.

The pain is the worst imaginable at the moment.

Personal Care

I can look after myself normally without causing extra pain.

I can look after myself normally but it causes extra pain.

It is painful to look after myself and I am slow and careful.

I need some help but I manage most of my personal care.

I need help every day in most aspects of self care.

I do not get dressed, I wash with difficulty and stay in bed.

Sleeping

I have no trouble sleeping.

My sleep is slightly disturbed (less than 1 hour sleepless).

My sleep is mildly disturbed (1-2 hours sleepless).

My sleep is moderately disturbed (2-3 hours sleepless).

My sleep is greatly disturbed (3-5 hours sleepless).

My sleep is completely disturbed (5-7 hours sleepless).

Lifting

I can lift heavy weights without extra pain.

I can lift heavy weights but it causes extra pain.

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table).

Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned.

I can only lift very light weights.

I cannot lift or carry anything at all.

Reading

I can read as much as I want with no neck pain.

I can read as much as I want with slight neck pain.

I can read as much as I want with moderate neck pain.

I cannot read as much as I want because of moderate neck pain.

I can hardly read at all because of severe neck pain.

I cannot read at all because of neck pain.

Driving

I can drive my car without any neck pain.

I can drive my car as long as I want with slight neck pain.

I can drive my care as long as I want with moderate neck pain.

I cannot drive my car as long as I want because of moderate neck pain.

I can hardly drive at all because of severe neck pain.

I cannot drive my car at all because of neck pain.

Concentration

I can concentrate fully when I want with no difficulty.

I can concentrate fully when I want with slight difficulty.

I have a fair degree of difficulty concentrating when I want.

I have a lot of difficulty concentrating when I want.

I have a great deal of difficulty concentrating when I want.

I cannot concentrate at all.

Recreation

I am able to engage in all my recreation activities without neck pain.

I am able to engage in all my usual recreation activities with some neck pain.

I am able to engage in most but not all my usual recreation activities because of neck pain.

I am only able to engage in a few of my usual recreation activities because of neck pain.

I can hardly do any recreation activities because of neck pain.

I cannot do any recreation activities at all.

Work

I can do as much work as I want.

I can only do my usual work but no more.

I can only do most of my usual work but no more.

I cannot do my usual work.

I can hardly do any work at all.

I cannot do any work at all.

Headaches

I have no headaches at all.

I have slight headaches which come infrequently.

I have moderate headaches which come infrequently.

I have moderate headaches which come frequently.

I have severe headaches which come frequently.

I have headaches almost all the time.

OUR SERVICES

Chiropractic

Activator

Acupuncture

Cupping

Webster Technique/Pre-Natal Care

Pediatric Care

Graston Self Tissue Therapy

Digital Xray

Treatment Modalities

Nutritional Supplementation

Kids's Week Special

Auto Injuries

Workman's Comp

Corporate Wellness

LOCATIONS

JUERGENS CHIROPRACTIC
1522 E Hintz Road 
Arlington Heights, Illinois 60004

Contacts

Phone: (847) 577-5400
Fax: (847) 577-5445