Health & Wellness What is the reason for your visit today? ☐ Wellness Check-Up ☐ Other Other: If other, how long has this been a concern? Is it getting worse? ☐ Yes ☐ No ☐ Not sure Does it affect activity? ☐ Not at all ☐ Somewhat ☐ Always Has anything been done already to address this concern?
Are any of the following symptoms present? Stomach pains Hyperactivity/Autism Leg/Knee pains Scoliosis
Allergies Growing Pains Headaches/Migraines Seizures Infections Tonsillitis Diarrhea Constipation Sleeping problems
Repeated colds Digestion General fatigue Acne/Skin problems Depression Menstrual cramps Anxiety Excessive hunger
Learning difficulties Low energy Asthma Irritability/Moodiness Low self-esteem
Other Do you participate in any athletic extra curricular activities? Yes/No If yes, which ones? Rate your diet: ☐ Well-balanced ☐ Average
☐ High sugar/processed foods
Do you consume artificial sweeteners? Yes/No Rate your exercise: ☐ Frequently How many glasses of water do you drink?
☐ Sometimes
☐ Never
/day
Number of hours you sleep?
hours/day
☐ Good
☐ Fair
☐ Poor
Sleep quality?
☐ Happy
☐ Melancholy
☐ Depends on the day
Rate your general mood:
Is there anything else you would like the Doctor to know?
Authorization to treat a Minor
I,
the undersigning parent/guardian having legal
custody/guardianship of , a minor, do herby authorize, request, and direct the staff and doctors of Collins Chiropractic to perform in judgment any examination and chiropractic diagnosis or treatment which is deemed necessary. Patient’s name: Parent/Guardian’s signature: Date:
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