Child's Name
*
First Name
Last Name
Phone Number
*
Email
*
Date of Birth
*
MM
DD
YYYY
Gender
Male
Female
Non-Binary/Gender Diverse
Prefer not to say
Address
*
Parent 1 Name
First Name
Last Name
Parent 2 Name
First Name
Last Name
How did you hear about our office and Network Chiropractic?
What concerns do you have regarding your child's health?
Were there any difficulties conceiving?
Were there any miscarriages prior to conception?
Did the mother smoke or drink during pregnancy
What, if any, form of exercise was done during pregnancy?
What was the diet like during pregnancy?
How was your child delivered?
Birth details can give vital clues as to potential spinal problems:
What was the timing of the child's birth
Was the child's head misshapen at birth?
Was the child's head bruised at birth?
Please list below if there any complications at birth
Right and Left breast fed evenly?
If so, is/was the colic
Does/Did your child have reflux?
When some stomach contents (eg breastmilk) pass from the stomach back up into a baby’s oesophagus, and sometimes spills out her mouth. This spilling, which can be called spitting up, posseting or bringing milk up, is common in babies, especially after a feed.
If so, was it "Silent Reflux"?
How does / did the baby sleep?
Did / does the baby move their bowels daily and easily?
Was / is the baby very irritable or unsettled?
Are you concerned about the shape of the baby's head?
Is or has your child ever experienced
Has your child met all developmental milestones?
Is the child rolling, sitting, crawling, walking consistently with development?
Has the child ever been hospitalised?
If so, please list below
Has the child had any significant falls/accidents?
If so, please list below
Has the child ever had any broken bones?
If so, please list
Has the child had any courses of prescription/non-prescription medication?
If yes, please list below the medication, duration and reason for medication
How you would you describe your child's eating habits?
Is there anything else you would like the chiropractor to know about your child or their family?
This may include family illnesses or any other concerns you have regarding family health.
Has there been any changes you've noticed in the child regarding
Relative to your child's emotions and relationships - Have you noticed a change relative to your child regarding
Relative to your child's learning - Have you noticed a change relative to your child regarding
Have there recently been any changes in lifestyle for your child relative to:
Do you give consent for your clinical information to be communicated to your general practitioner or preferred health practitioner? *
Our practice specialises in treating problems of the spine and associated disorders of the nervous system. A proportion of our patients come via referral from their medical practitioner. As such, it is standard practice to correspond with your medical practitioner where appropriate.