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IMMUNE SUPPORT
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WHAT IS BGI
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THE ONLY CONSTANT
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MULTIPLE DIMENSIONS OF THE SPINE
COMMITMENT
ADHD CASE STUDY
EAR INFX
Can't Nurse?
HEALTHY KIDS
THE VACCINE BUBBLE
C SECTION FACTS
SCHEDULE HERE
BABY
HISTORY
FORM
1.
PLEASE START HERE BY SIGNING OUR HIPPA FORM!
2. PLEASE BE AS DETAILED AS POSSIBLE SO THAT WE CAN BEST SERVE YOU.
*
Indicates required field
Child's Name
*
First
Last
Date of Birth
*
Phone Number
*
Who is your cell phone provider for appt. reminders?
*
Option 1
Option 2
Option 3
ATT
VERIZON
SPRINT
T Mobile
Cricket
Other
Email
*
Parent / Guardian's Name(s)
*
Where would you like to see us:
*
Clinton
Princeton
Address:
*
Line 1
Line 2
City
State
Zip Code
Country
Names and Ages of Siblings:
*
Is there anyone else at home that would like an appointment with Dr. Jodi at this time?
*
How did you hear about us?
*
A friend / family / practitioner
Online search
Facebook
Drive by
Other
If you heard about us through a friend / family / practitioner, please share their name so that we can thank them!
*
We will check your insurance for you. Please disregard if you have an HMO or no insurance.
INSURANCE COMPANY
*
PRIMARY INSURED
*
ZIP CODE OF INSURANCE
*
POLICY NUMBER
*
PRIMARY INSURED DOB
*
GROUP NUMBER
*
INSURANCE PHONE NUMBER
*
Let us know how we can help:
Please list all health issues that your child experiences:
*
Why are you seeking treatment for your child in our office at this time?
*
What do you hope for your child to get out of their experience at LightSource Chiropractic?
*
Please describe your child's personality, nature, and anything that makes them unique.
*
Do you or your spouse have any fears / concerns about your child seeing Dr. Jodi?
*
PLEASE LIST YOUR CHILD'S HEALTH CARE PROVIDERS AND WHAT YOUR CHILD SEES THEM FOR
*
What are the TOP THREE ATTRIBUTES you look for in a family practice for your family?
*
When was your child's last check up and what did you learn about your child?
*
On a scale of 1-10, 10 being your child's BEST possible health and 1 being VERY SICK, where do you feel your child is at today?
*
Chemical Stresses:
Everyday chemicals can create tension in the body; causing great health issues.
Please tell us about your baby's diet:
*
I am nursing exlusively
I am nursing and we supplement with formula (let us know what kind of formula in comments field)
I am using formula, no nursing
My baby is on solids at this point
Types of formula or solids?
*
If you are nursing, are there foods that you avoid?
*
What daily chemicals does your child come in to contact with that are not organic / all natural?
*
Laundry soap
Shampoo, soap, bubble bath
Diapers, wipes
Creme
Mom / Dad perfume / deodorant
Air freshners
Candles
Dish soap / household cleaners / floor cleaner / carpet perfumes or cleaners
Please list all medications and supplements your child is currently take, amount and what they take them for:
*
Is your child vaccinated? If so, has your child had any adverse reactions or symtoms following their vaccines?
*
Physical Stresses
The average child falls 2500 times in their first five years of life. There is up to 90 pounds of pressure put on the spinal cord at birth. These stresses add up and create all kinds of health issues!
Please tell us about your child's birth history. Include where they were born, who your practitioner was, any intervention, drugs, epidurals, surgery, etc.
*
Please list any surgeries your child has had, include date and reason:
*
Has your child ever been to a chiropractor? If so, when was their last adjustment and with whom? What did you love most about their care? Least? If your child has never seen a chiropractor, why not?
*
Please tell us about your child's sleeping patterns:
*
Please list any injuries your child has experienced. Let us know how it happened and what the treatment for it was.
*
How often do you burp your baby? Please describe what you do. (This is important to a chiropractor!).
*
Is there anything else you would like us to know about?
*
Why does NOW feel like a good time for your child to receive care with Dr. Jodi?
*
Submit
GET STARTED
YOU ARE LOVED
First Visit
MONEY STUFF
>
CHIROHEALTH USA
CHECK MY INSURANCE
Videos of our care
ABOUT OUR PRACTICE
OUR STATEMENT OF PURPOSE
MEET YOUR CHIROPRACTOR
BRAG PAGE
Current Patients
CURRENT PATIENT SCHEDULING
RE EVALUATION
CONTACT & LOCATIONS
FACEBOOK
FIND US!
Review us online!
JOIN OUR TEAM
BLOG
RESOURCES
Dr. Jodi Dinnerman.com
FAQ
AMAZING FAMILY MAGAZINE
BIRTHFIT
LIFE WELLNESS PRODUCTS
ARTICLES FOR EDUCATION
>
IMMUNE SUPPORT
GLUTEN / DAIRY FREE
MERRIC CHART
LYME TESTING
THE GEOMETRY OF THE SYSTEM
WHAT IS BGI
CHIRO FOR SAFER PREGNANCY
THE ONLY CONSTANT
THE CHIROPRACTIC OATH
MULTIPLE DIMENSIONS OF THE SPINE
COMMITMENT
ADHD CASE STUDY
EAR INFX
Can't Nurse?
HEALTHY KIDS
THE VACCINE BUBBLE
C SECTION FACTS
SCHEDULE HERE