Homefarm Family Chiropractic - Chiropractor In Drumcondra, DUB Ireland :: Children (Newborn - 16 years) New Patient Health History Form

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Home > Children (Newborn - 16 years) New Patient Health History Form

In order to provide you the best possible wellness care, please complete this form

Patient Data

First Name *

Last Name *

Date

Email (Your email will NOT be shared with any third parties, and is used for occasional office announcements and promotions.) *

Mailing Address

Address

City

State

Zip

Telephone (Home)

Telephone (Work)

Referred By

Age

Birth Date

Number of Children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Phone

Current Complaints

Nature of Injury

Automobile*

Work

Other

Please Describe

Date of Injury

Date Symptoms Appeared

Have you ever had same condition?

Yes

If yes, when?

List other practioners seen for this injury/condition

Have you ever been under chiropractic care?

Yes

If yes, please describe

Medical History

Have you been treated for any conditions in the last year?

Yes

If yes, please describe

Date of last physical exam

Is there a chance that you are pregnant?

Yes

Have you had X-rays taken?

Yes

If Yes, where?

What medications are you taking and for what conditions (Please list dosage and amounts, etc).

What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).

Have you ever:

Broken bones?

Yes

Briefly explain

Been hospitalized?

Yes

Briefly explain

Been in auto accident?

Yes

Briefly Explain

Had Sprains/Strains?

Yes

Briefly explain

Been struck unconscious?

Yes

Briefly explain

Had surgery?

Yes

Briefly explain

Family History

Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Do you experience pain every day?

Yes

Do your symptoms interfere with daily life?

Yes

Does pain wake you up at night?

Yes

Are your symptoms worse during certain times of the day?

Yes

Do changes in weather affect your symptoms?

Yes

Do you wear orthotics?

Yes

Do you take vitamin supplements?

Yes

What activities aggravate your symptoms?

Habits

Alcohol

None

Light

Moderate

Heavy

Coffee

None

Light

Moderate

Heavy

Tobacco

None

Light

Moderate

Heavy

Drugs

None

Light

Moderate

Heavy

Exercise

None

Light

Moderate

Heavy

Sleep

None

Light

Moderate

Heavy

Appetite

None

Light

Moderate

Heavy

Soft Drinks

None

Light

Moderate

Heavy

Water

None

Light

Moderate

Heavy

Salty Foods

None

Light

Moderate

Heavy

Sugary Foods

None

Light

Moderate

Heavy

Artificial Sweeteners

None

Light

Moderate

Heavy

Have you ever suffered from:

Other

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Experience for yourself why our patients rate us the highest for quality effective health care and pain relief.

Call if you'd like a FREE Appointment for: Spinal Health Screenings and/or Backpack Safety Instructions.

We truly care about our community and consider it an honour to help our patients achieve their health and wellbeing goals.

Do you have questions about Chiropractic? Watch the videos below.

Call us at (01) 561 3000

Our Services

We strive to provide complete care for our patients. Learn more about all the services we provide.

View Services

Testimonials

Awarded by
WhatClinic.com

I have benefited tremendously from the chiropractic care I received from Dr. Maureen"   - JD

(before care-)

"I woke up and everything around me was spinning..."

(after care-) "I started to believe again that I could have my life back.... I want to say thank you with all my heart. "   Ionela E.

"...the pain I was going through for months has gone away..." S.K.

The clinic was open, friendly and in a handy location. I really enjoy going to see her and she is so warm and welcoming and makes you feel relaxed and at ease. She is also so passionate and helpful if you have any queries. Well worth a visit."

Gill

****

Please see our Testimonials Page (link above) to read more about what these and many others are saying about their health & wellbeing under Dr. Maureen's care.

Office Hours

Day	Calls taken when closed	Phone is forwarded to Dr.
Monday	... 11 a.m. - 7 p.m.	lunch 3 - 5
Tuesday	... 8 a.m. - 7 p.m.	lunch 11 - 2
Wednesday	... 11 a.m. - 7 p.m.	lunch 3 - 5
Thursday	... 8 a.m. - 7 p.m.	lunch 11 - 2
Friday	... 11 a.m. - 7 p.m.	lunch 3 - 5
Saturday	... 9 - 12	closed
Sunday	Dr. may be available for Emergency visits outside normal hours	Emergency fees will apply outside of normal hours

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