It is our pleasure to welcome you to our family of happy and healthy chiropractic members. Please let us know if there is any way we can make you and your family feel more comfortable. Many types of stressors (physical, mental and chemical) can interfere with your child’s growing brain, spine and nervous system. To help us serve you better, please complete the following history information about your child. We look forward to working with you to build a better future for your family.

Please provide the name, age, and gender for each of your children, if applicable.

How does your present problem(s) affect the following hobbies, exercise, and recreational activities.

Chiropractic care, like all forms of health care while offering considerable benefits may also have some level of risk. The level of risk is most often very minimal, yet in rare cases, injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include: temporary worsening of symptoms, sprain/strain, irritation of a pre-existing disc condition, and rarely, fractures. Chiropractic treatment has also been associated with stroke. However, that association occurs very infrequently, and may be explained because an artery was already damaged and the patient was progressing toward a stroke when the patient consulted the chiropractic. Present medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke. Chiropractic care has been demonstrated to be effective for complaints of the neck, back and other areas of the body including organ dysfunction caused by nerves, muscles, joints and related tissues. It can also increase mobility, improve function, and reduce or eliminate the need for drugs or surgery. Prior to receiving chiropractic care in this practice, a health history and physical examination will be completed. These procedures are performed to assess your specific concerns, your overall health and in particular the state of your nerve system. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In Addition, they will help us determine if there is anyr eason to modify your care to provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan prior to beginning care. I understand and accept the above information associated with chiropractic care and give consent to the examination and chiropractic care, including spinal adjustments after my findings have been reported. I have not signed this prior to having my questions or concerns addressed and discussed.