PEDIATRIC HISTORY FORM

Infinite Health Center

PATIENT DEMOGRAPHICS

CHILD’S CURRENT PROBLEM:

Purpose of this visit*

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Ever had this problem before*

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How long ago?*

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How is this problem now?*

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Has your child ever suffered from:*

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I understand that I am directly and fully responsible to this office for all fees associated with chiropractic care my child receives.

The risks associated with exposure to x-rays and spinal adjustments have been explained to me to my complete satisfaction, and I have

conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request and authorize imaging studies and

chiropractic adjustments for the benefit of my minor child for whom I have the legal right to select and authorize health care services on

behalf of. I hereby request and authorize this office to administer healthcare as deemed necessary to my dependent minor child. This

authorization also extends to include diagnostic imaging, laboratory and other testing at the doctor’s discretion.

Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify this office.*

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Activities of Daily Living/Symptoms/Medications

Daily Activities: Effects of Current Conditions on Performance:

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

Bending*

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Doing computer Work*

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Concentrating*

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Gardening*

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Playing Sports*

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Recreation Activities*

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Shoveling*

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Sleeping*

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Watching TV*

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Carrying*

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Dancing*

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Dressing*

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Lifting*

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Pushing*

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Rolling Over*

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Sitting*

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Standing*

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Working*

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Climbing*

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Doing Chores*

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Driving*

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Performing Sexual Activity*

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Reading*

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Running*

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Walking*

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Sitting to Standing*

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For Office Use Only

I have reviewed the above ADL & ROS form with the above named patient:

Thank you for taking the time to fill out this form.

Appointments Available

Call 505-772-0114

Our Patients Have Experienced Great Results With…

• Headache / Migraines
• Back and Neck Pain
• Scoliosis
• Postural Deformities
• Low Metabolism
• Fatigue
• Acid Reflux / GERD
• Frozen Shoulder
• High Blood Pressure
• Plantar Fasciitis
• Allergies
• Asthma
• Shoulder Pain
• Disc Herniation
• Trouble Sleeping

$99 New Patient
Exam + Consult

See If We Can Help You

Infinite Health Center is far more than I expected! The amazing customer service, knowledgeable Doctors, and overall positive energy of the center makes it easy to keep appointments and get motivated to live a healthier life. 11/10 recommend!

Rhonda Montoya

I wholeheartedly recommend Infinite. The staff is friendly, accommodating and most of all, caring. The doctors are superb and treat you like family. They address you by name and take time to hear your concerns or reservations. I look forward to the continued progress I am making. Thank you, Infinite!

Emily Montoya

Friendly, knowledgeable, personal, and accommodating! Really enjoy my experience with care and staff as well as reduced headaches! Having a family of 6 and living a distance has not been an issues! If you are serious about your health and are looking for an overall solution, not just temporary treatment, this is the place to go!

Jessica Casados

See More Reviews

Infinite Health Center
2860 Cerrillos Road
Suite C-2
Santa Fe, NM 87507

Monday 9–11:30AM, 2:30PM–6:00PM
Tuesday 2:30PM-6:00PM
Wednesday 9-11:30AM, 2:30PM–6:00PM
Thursday 2:30PM-6:00PM
Friday 9:00AM-11:30AM

Closed Saturday and Sunday