Baby Treatment Form

Please take the time to carefully fill out the medical history form. It is a very important basis for the first treatment of your child in our practice. If you do not wish to provide certain personal information in writing, you are free to do so. Your information will of course be treated confidentially and is subject to medical confidentiality.

Thank you very much.

(Fields marked with * are required)

Details of the parents

Salutation *

Title

First name *

Family name *

Telephone no. *

Telephone type

Email *

Street/Number *

ZIP code *

Place of residence: *

Details of the child

Gender *

First name *

Family name *

Date of Birth *

Number and age of siblings

How is your child insured?

With which health insurance company is your child covered?

How did you find out about our practice?

Patient

Doctor/Therapist

Midwife

Google

Evaluation portal

Social Media

Through the Press

Clinic sign

Car advertising

Watch advertising

Presentation

Other

During pregnancy

Have any medications (antibiotics, magnesium, etc.) been taken?

Yes No

Were there any accidents/falls?

Yes No

Were there any operations?

Yes No

Were there any other problems/complications?

Mother

Yes No

Child

Yes No

Birth

Birth weight in g

Length in cm

Head circumference

How long did the birth last from labor?

Were any aids (suction cup, forceps) used?

Yes No

Was a PDA used?

Yes No

Was the birth by cesarean section?

Yes No

Other?

Yes No

Wich the birth by more than a week from the calculated date?

Yes No

Was your child in a malposition (e.g. breech presentation, transverse presentation)?

Yes No

After birth until today

Have any medications been or are being taken?

Mother

Yes No

Child

Yes No

Has the child been vaccinated?

Yes No

Were there any abnormalities in the standard examinations (U1, U2, etc.)?

Yes No

Has your child fallen or had an accident?

Yes No

Did your child have a broken bone or sprain?

Yes No

Has your child received any other examinations or treatment?

Yes No

Behavior of your baby

On average, how many hours a day does your child cry?

How often is your child up at night?

Is or was your child exclusively breastfed?

Yes No

Does your child nurse equally well on both sides?

Yes No

Does your child spit up and/or drool frequently?

Yes No

How often does your child have bowel movements?

Has your child had difficult defecation

Yes No

How is the weight gain of your child?

Does your child cry when dressing and undressing?

Yes No

Are there any abnormalities in general contact with your child?

Yes No

Posture/motor skills of your baby

Is your child overstretching, making himself stiff?

Yes No

Does your child often lie in a supine position in an arc like a "C"?

Yes No

Does your child dislike lying on his stomach?

Yes No

Does your child hold their head turned and/or tilted?

Yes No

Does your child turn his head in one direction worse?

Yes No

Does your child have a flattened back of the head?

Yes No

Have you noticed asymmetric movement patterns in your child (e.g., uses the right arm significantly more than the left arm, turns predominantly in one direction)?

Yes No

Conclusion

What else would you like to tell us?

IHR-CHIROPRAKTOR is welcome to contact my doctor

Ich stimme der Kommunikation über mich im Rahmen eines gemeinsamen therapeutischen Projekts mit anderen Praxen oder Therapeut:innen zu.

I hereby expressly agree to the transmission of my personal data to my health insurance company for the purpose of accounting.

Fee agreement * (less information)

Cost of Treatment (as of 01.09.2022)

First treatment/Consultation

(30min): 100,00 Euro

(40min): 120,00 Euro

(50min): 140,00 Euro

Follow up treatments

(20min): 80,00 Euro

(30min): 100,00 Euro

(40min): 120,00 Euro

(50min): 140,00 Euro

(60min): 160,00 Euro

Please inform yourself if you might be reimbursed by your health insurance for chiropractic care. Usually the insurance will not cover the cost of treatment in this practice.

If you have to cancel an appointment please do within 24hours. For cancellations later than that or no-shows we will invoice half of the treatment cost of the missed appointment.

With this signature you consent that you personally would like to have treatment in this practice.You have been informed that a Chiropractic treatment will not be paid for by your health insurance. We will not proof or check for any possible reimbursement by your health insurance.
Invoices will not be changed retrospectively.

Data Protection * (more information)

I have read the complete privacy policy under the link Data-Protection and declare my consent to the collection and use of my personal data provided within the framework of the treatment contract.

Riskinformation / Risk disclosure * (less information)

The duty of care and education requires us to inform every patient about possible risks.

Treatment risks:

Performed by a qualified chiropractor, chiropractic offers a relatively low-risk treatment option for diseases of biomechanical origin.
There are no known risks associated with chiropractic correct treatment of joints in the arms and legs. The chiropractic treatment of the lumbar and thoracic spine is also very low risk. Only in 1:100,000 cases could occur a nerve damage.
Studies show that the risk of injury/damage to the cervical vertebral artery (Ateria vertebralis) is even lower when the cervical spine is chiropractically adjusted. A stroke can only occur in 0.64 out of 1,000,000 cases. However, it should be noted that in patients with pre-damaged blood vessels (risk factors: smoking, overweight, diabetes etc.) normal everyday behaviour, such as looking over the shoulder while driving a car, could also lead to such a complication.

Treatment reactions:

After the treatment, pain like delayed onset of muscle soreness might occur sometimes within the first 48 hours. Usually these disappear quickly when the affected areas are cooled. Temporary tiredness and/or headaches may also occur. A certain feeling of instability may also occur in the treated area for some time. If you need further information, please contact your treating chiropractor.

I feel sufficiently informed about the risks of chiropractic treatments. I have read and understood the above explanations. I agree with a treatment. Risik information confirmation

Knowledge and conscience Headline *

My information in the treatment form is correct. I have given the information to the best of my knowledge and belief.

Printout for your own records

Baby Treatment Form

Details of the parents

Details of the child

During pregnancy

Birth

After birth until today

Behavior of your baby

Posture/motor skills of your baby

Conclusion

Name and adress of the doctor