• Image field 251
  • Sex

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Has your child ever received chiropractic care?
  • PRESENT HEALTH COMPLAINTS/CONCERNS:
  • Is this problem:
  • Does this problem radiate?
  • Is the problem worse during a certain time of the day?
  • Does this interfere with the child's (check)

  • OFTEN SEEMINGLY UNRELATED SYMPTOMS CAN MANIFEST AS OTHER HEALTH CONCERNS: (please check if your child has had or has any of the following):

  • HISTORY OF BIRTH
  • Was your child"s birth:
  • Was the birth considered:
  • Was child born:
  • Were there any complications?
  • Please check any assistance which was used during the birth:
  • Was labour:
  • Were medications or epidurals given to the mother during birth?
  • GROWTH & DEVELOPM ENT
  • Was the infant alert and responsive within 12 hours of delivery?
  • At what age did the child:
     
  • Do you consider the child's sleeping pattern normal?
  • FAMILY HEALTH HISTORY
  • Please note any health problems (ie. cancer, hereditary conditions, diabetes, heart disease, etc.) that are present in:

  • Since problems that chiropractors look for and detect can be related to many types of stressors, the following information is also very important to us. 

  • PHYSICAL STRESSORS
     
  • Any traumas to the mother during pregnancy? (ie. falls, accidents, etc.)
  • Any evidence of birth trauma to the infant? (please check)
  • Any falls from couches, beds, change tables, etc?
  • Any hospitalizations or surgeries?
  • Is a school backpack used?
  • Is it:
  • CHEMICAL STRESSORS
  • Was this child breast-fed
  • Food/Juice intolerance
  • During the pregnancy, did the mother smoke?
  • During pregnancy, did the mother drink?
  • Any illness during the pregnancy?
  • Any supplements taking during pregnancy?
  • Any drugs taken during pregnancy?
  • Any ultrasounds?
  • Any invasive procedures during pregnancy? (ie. amniocentesis, CVS, etc.)?
  • Any pets at home?
  • Any smokers in the home?
  • PSYCHOSOCIAL STRESSORS
  • Any difficulties with lactation?
  • Any problems with bonding?
  • Any behavioural problems?
  • Any night terrors, sleep walking, difficulty sleeping?
  • Do you feel that your child's social and emotional development is normal at their age?

  • Thank you for completing our Child Health History Questionnaire. If there are any other questions or concerns which you have, you may write them down in the space below.

  • Should be Empty: