Child's Name *

First Name

Last Name

Parent 1 Name

First Name

Last Name

Parent 2 Name

First Name

Last Name

During you pregnancy, did you have any of the following:

Falls?

Motor Vehicle Accidents?

Near-miss Motor Vehicle Accidents?

High Blood Pressure?

Diabetes?

Anemia?

Morning Sickness?

Indigestion?

Seizures?

Swollen Ankles?

Thyroid Problems?

Heart Problems?

Back Pain?

Abnormal Bleeding?

Were you Hospitalised?

Any Other Illnesses?

Emotional Upsets?

During your pregnancy, did you have any changes in circumstances?

Move

Martial Status

Financial Stress

Work

Other

Was your Child's birth:

Hospital Birth

Home Birth

Midwife Assisted

Vaginal Delivery

Planned C-Section

Emergency C-Section

Was Birth Induced (Pitocin)

Forceps Delivery

Vacuum Extraction

Anaesthesia Administered

Fetal Distress

Meconium Staining

Head Presentation

Face Presentation

Breech Presentation

Baby's cry?

Baby Cried Immediately After Birth

Strong Cry

Weak Cry

Did not Cry for ___ Minutes

Baby's colour?

Pink All Over

Blue Face

Blue Hands/ Feet

Baby's activity?

Arms and Legs Actively Moving

Floppy Baby

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.

I give consent

I do not give consent