Child's Personal Information
Child's Name
Parents'/Guardians' Names
Address
City/Postal Code
Parents' Email Address (for Patient Newsletter)
Child's Birth Date
Child's Gender Male Female
How did you learn about our centre?
Child's Medical History
Has your child previously been under chiropractic care? Yes No
If so, when?
Please check your reasons for pursuing chiropractic care for your child She/He is continuing care from another chiropractor I recently had my spine checked and I see the value in getting my child checked I'm concerned about her/his health and I'm looking for answers I want to improve my child's immune system function I have no idea why we're here. Please take the time to explain to me what you do for kids She/He has a specific condition that concerns me
If your child has a specific condition or symptom, please explain
As a child or adolescent, has or does your child experience any of the following? Headaches Allergies ADD/ADDH Growing/Back pains Sinus problems Learning disabilities Postural imbalance Ear infection PDD/Autism Digestive problems Bedwetting Asthma Scoliosis Seizures Frequent colds Colic
Any other conditions?
List known allergies
List prescription or over-the-counter medications now taken
Number of doses of antibiotics your child has taken during the past 6 months
Number of doses of antibiotics your child has taken during his/her lifetime
List reasons for your child taking antibiotics
Number of doses of other prescription medications your child has taken in the past 6 months
Number of doses of other prescription medications your child has taken during his/her lifetime
List reasons for your child taking prescription medication
Prenatal History
Was your child adopted? Yes No
Duration of gestation (in weeks)
Did you experience any complications during pregnancy? Yes No
If so, what were they?
Did you have any ultrasounds during pregnancy? Yes No
If so, how many?
Did you take medication/drugs/caffeine during pregnancy? Yes No
If so, which?
Did you use cigarettes or alcohol during pregnancy? Yes No
Where was your child born (name of hospital or center, or at home)?
Did you use: Midwife Doula Obstetrician
Birth Intervention
Did you have a C-section? Yes No
Were forceps used? Yes No
Vacuum extraction? Yes No
Were you induced? Yes No
Did you have an epidural? Yes No
Was it a difficult birth? Yes No
Was the baby's skull/head mis-shapen? Yes No
Purple markings on face? Yes No
Complications during delivery? Yes No
If so, please list
Was your child breastfed? Yes No
How long did you breastfeed your child?
Was your child formula fed? Yes No
How long did you feed your child formula?
Does your child have any food allergies or intolerances? Yes No
Were there any reactions to vaccinations? Yes No
Child's Trauma History
As a baby/toddler/young child did any of the following occur? Fall from change table Car accident Fall from a tree Tumble down stairs Fall from playground equipment Fall off a bicycle Fall out of crib Play in 'jollyjumper' Sports accident
Has your child been involved in any contact sports? Yes No
Has your child been seen on an emergency basis? Yes No
If so, why?
Describe any hospital stays or surgeries
Is there anything else you feel we should know?
Thank you for submitting your form online!