• The purpose of our office is to restore and maintain the health of our patients through natural chiropractic methods. Please complete this confidential health questionnaire fully and accurately. The more we know about the overall picture of your child's health, the better we will be able to help you.
  • Patient Demographics

  • Date Format: MM slash DD slash YYYY
  • History of Complaint

    Please identify the complaints/reasons for your child's visit to our office (i.e. wellness check-up, injury):
  • On the scale of 0 to 10, with 10 being the most significant, rate the above complaints by entering the number:

  • Past History

  • Broken Bone
    Rheumatoid Arthritis
    Heart Attack
    Osteo Arthritis
    Other serious conditions:
  • Social History



    "The nervous system controls and coordinator all organs and structures of the human body." (Gray's Anatomy 29th ED., page 4). Misalignments vertebrae and disc may cause irritation to the nerves which could affect the area listed. Please help us help you by placing a check mark in the appropriate box under the "Possible Effects" column to indicate your symptoms.
  • Possible Effects of a Malfunction
  • Possible Effects of a Malfunction
  • Possible Effects of a Malfunction
  • Possible Effects of a Malfunction
  • - I would like to communicate by email with Vida Chiropractic.

    - I will be responsible for maintaining any information regarding my care that I have saved onto my personal computer.

    - I understand that my email authorization and a copy of the email guidelines I have received will become part of my permanent medical record.

    - I agree to follow the guideline for email communication with Vida Chiropractic and will use email for non-emergency purposes only.

    - Emails containing transitory information (routine or short term transactions, and contain little or no information of ongoing value, i.e. confirmation of appointments) will be securely deleted by the Clinic.

    - Email correspondence containing clinical or significant information will be entered into my permanent medical record by Vida Chiropractic.

    - I agree to inform Vida Chiropractic if my email address changes.

    - I understand that the Clinic will normally respond to email communications within 1 business day. If I have not heard from the Clinic by this time, I will phone the Clinic.
  • The email I would like to have on file is a personal, non-shared, confidential email. I assure Vida Chiropractic that information sent to this email is secure and does not place Vida Chiropractic at risk of breaching confidentiality or privacy regulations.

    The Statements made on this form are true to the best of my knowledge and I consent to allow Vida Chiropractic to further evaluate my condition with an exam and other tests as deemed necessary by the doctors.
  • This field is for validation purposes and should be left unchanged.