Child's Personal Information
Parents' Email Address (for Patient Newsletter)
Child's Birth Date
How did you learn about our centre?
Child's Medical History
Has your child previously been under chiropractic care?
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?
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
Was your child adopted?
Duration of gestation (in weeks)
Did you experience any complications during pregnancy?
If so, what were they?
Did you have any ultrasounds during pregnancy?
If so, how many?
Did you take medication/drugs/caffeine during pregnancy?
If so, which?
Did you use cigarettes or alcohol during pregnancy?
Where was your child born (name of hospital or center, or at home)?
Did you use:
Did you have a C-section?
Were forceps used?
Were you induced?
Did you have an epidural?
Was it a difficult birth?
Was the baby's skull/head mis-shapen?
Purple markings on face?
Complications during delivery?
If so, please list
Was your child breastfed?
How long did you breastfeed your child?
Was your child formula fed?
How long did you feed your child formula?
Does your child have any food allergies or intolerances?
Were there any reactions to vaccinations?
Child's Trauma History
As a baby/toddler/young child did any of the following occur?
Fall from change table
Fall from a tree
Tumble down stairs
Fall from playground equipment
Fall off a bicycle
Fall out of crib
Play in 'jollyjumper'
Has your child been involved in any contact sports?
Has your child been seen on an emergency basis?
If so, why?
Describe any hospital stays or surgeries
Is there anything else you feel we should know?
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