Child Spinal And Postural Examination Form

It is our pleasure to welcome you to our clinic. Please carefully complete the following questionnaire. Your answers will help us to determine how chiropractic may benefit your child.

Name of Child:*
Date of Birth:*
DD slash MM slash YYYY
Age:*
Mother's Name:*
Phone:*
Father's Name:*
Phone:*
Address:*
Email:*

Other Children's Names (Have they had a previous chiropractic examination?)

Name	D.O.B.	Age:	Child had a previous chiropractic exam?	Actions
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There are no Children.

Maximum number of children reached.

How did you hear about our practice?*
Other:
What concerns do you have regarding the health of your child?
PREGNANCY
Did you require any medication through your pregnancy?*
- Yes
- No
Details of your medication through your pregnancy:*
Were there any complications through your pregnancy?*
- Yes
- No
Details of the complications through your pregnancy:*
BIRTH
The birth of your child can give vital clues as to potential spinal problems. Please answer the following questions about the delivery and birth of your child.*
- Home / Hospital Delivery
- Drugs during delivery
- Normal vaginal
- Posterior
- At Term
- Late
- Breech
- Premature
- Caesarian
- Forceps
- Suction
- Chemically Induced
- Other
Other:*
Birth Weight:*
APGAR Scores at Birth:*
APGAR Scores at 5 minutes:*
How long were you in labour? (in Hours)*
How long did you "push" for? (Mins/Hours)*
Do you believe the birth was traumatic for your child?*
- Yes
- No
Was your child's head mis-shaped at birth?*
- Yes
- No
Were there any delivery complications?*
- Yes
- No
Details:*
BIRTH TO SIX MONTHS
Was your child breast fed?*
- Yes
- No
For how long?*
Were there attachment issues?*
- Yes
- No
Details:
Was your child formula fed?*
- Yes
- No
For how long?*
Type*
Did your child suffer with colic?*
- Yes
- No
How bad was the colic?*
Did your child suffer with reflux?*
- Yes
- No
How bad was the reflux?*
What type of sleeper your child is?*
OTHER PROBLEMS
Please indicate by ticking any of the following conditions which your child has experienced in the past:*
- Headache
- Back pain
- Sinus pain
- Recurrent chest infections
- Loss of appetite
- Allergies
- Constipation/Diarrhoea
- Recurrent tonsillitis
- Growing pains
- Poor sleeping habits
- Arm/ Leg pain
- Fever
- Asthma
- Seizures
- Hip problems
- Poor Social Skills
- Neck pain
- Earaches/Infections
- Bedwetting
- Hyperactivity
- Constant fatigue
- Scoliosis
- Joint pains
- Night terrors
- Recurring fevers
- Developmental Delay
- Other
Other*
SCHOOL AGE CHILD
Please indicate by ticking any of the following conditions which your child has experienced as a School Age Child in the past:*
- Poor co-ordination
- behavioral Issues
- Diagnosis of Autism
- Learning difficulties
- Poor handwriting
- Diagnosed as ADD/ADHD, Delayed verbal communication
- Difficulty With Reading/Writing/Spelling
- Extreme clumsiness
- Visual Disorders
- Recurrent stomach aches
- Convulsions
- Travel sickness
- Chronic colds
- Digestive disorders Extremely messy eater
- Other
Other*
MEDICAL HISTORY
What age did your child begin crawling?*
How long did your child crawl for?*
Is your child accident prone?*
- Yes
- No
Has your child has any significant falls?*
- Yes
- No
Please describe any falls or accidents your child has had.
Has your child ever been involved in a motor vehicle accident?*
- Yes
- No
Is your child on medication?*
- Yes
- No
Details of your Child's Medication:
Is your child vaccinated?*
- Yes
- No
Details of your Child's Vacination:
Has your child had any diseases/illnesses?*
- Yes
- No
Details of your Child's Diseases/Illnesses:
Has your child ever been hospitalised or had surgery?*
- Yes
- No
Details of Hospitalisation or Surgery:
Has your child ever had any broken bones or sprain injuries?*
- Yes
- No
Details of Broken Bones or Sprain Injuries:
Has your child ever been assessed for the presence of scoliosis?*
- Yes
- No
How many times has your child taken antibiotics in last six month?*
How many times has your child taken antibiotics during lifetime?*
How many doses of other Prescription Medication has your child taken in last six months?*
What was the medication for?*
PREVIOUS CHIROPRACTIC CARE
Has your child had previous chiropractic care?*
- Yes
- No
Reason for care:*
Date of last care:*
DD slash MM slash YYYY
Name of Chiropractor:
Location of the Clinic:*
Were x-rays taken?*
- Yes
- No
How would you describe the care received?*
- Excellent
- Good
- Fair
- Poor
Further Comments:*

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Child Spinal And Postural Examination Form

PREGNANCY

BIRTH

BIRTH TO SIX MONTHS

OTHER PROBLEMS

SCHOOL AGE CHILD

MEDICAL HISTORY

PREVIOUS CHIROPRACTIC CARE