Naturally Chiropractic | Child History Form

Tynemouth's premier chiropractic care facility

New Patient history: Children

Please fill in as much of this form as you can and tick where appropriate.

Areas marked with * must be filled in.

Child’s first name*

Surname*

Date of birth

Age

Address

Town

Postcode

Parents names *

Your body is designed to be healthy. There is always a cause or reason as to why it is not.

All the information you supply here will be handled in strict confidence. The answers will help us assess any layers of damage, particularly to your nervous system, that have adversely affected your health.

Can we check that you have read these pages:

You can do this later, but you won't be able to submit this form unless you can confirm you have done so at the bottom of the form.

Contact numbers

Email *

Name of GP

Why are you bringing your child to the clinic?

Did your pregnancy go to full term?

Please describe any problems you had during your pregnancy, however minor

Did you have any ultrasound scans?

Did you have other tests (e.g. amniocentesis?)

Has your child ever had chiropractic care?

How did you hear about Naturally Chiropractic?

Yes

No

for how long

Yes

No

Yes

No

How many?

If yes, please list

How long did they last?

Did you take any prescribed medication during your pregnancy?

Did you use any homeopathic remedies or supplements?

Did your labour start naturally or through induction?

How long did your labour last once established?

Did you have any form of pain relief during the labour?

Did you have any form of intervention? (e.g. forceps, ventouse)

Was mum involved in any accidents prior to conceiving or during pregnancy?

Vaccinations

Please list any vaccines your child has had

Did they suffer any reaction to any of the vaccinations given?

If yes, please tick any of the relevant reactions below:

Allergies

Fever

Convulsions

Irritability

Asthma

Ear infections

Sleeping difficulties

Eating difficulties

Swelling at injection site

Autism or learning difficulties

Any other reactions?

Feeding

Are/were they breast fed

Yes

No

for how long

Does/did mum suffer from any discomfort, breast or nipple problems?

Please describe

Yes

No

Do/did they feed better to one side

Yes

No

Which side ?

Left

Right

Do they feed efficiently and well?

Yes

No

Please describe

Do they suffer any food allergies or intolerances?

Yes

No

Please describe

Nappies

How often do they fill their nappies?

What colour is it when they do?

Do they struggle to
poo or pass wind?

Sleep

Do they sleep well?

Are they swaddled?

Yes

No

Yes

No

Do they sleep on their:

Front

Back

Side

Have they had any hospitalisations? If so, please describe.

Have they had any childhood illnesses?

Do they suffer from any of the following? If yes, please tick boxes:

Headaches

Ear infections

Sore throat

Concentration issues

Tonsillitis

Hoarse voice

Swallowing

Jaw pain or clicking

Neck pain

Asthma

Conjunctivitus

Wind

Sight problems

Hearing problems

Sinus problems

Stomach aches

Growing pains

Epilepsy or fits

Diarrhoea

Constipation

Fainting

Fatigue

Rashes

Loss of consciousness

Are they:

Do they play sports?

If yes, please describe

Clumsy

Coordinated

Please describe any current health issues or concerns

Please note that by submitting this form you are giving us permission to contact you by the methods listed above.
Your details will be held on our database but will not be passed to third parties at any other time.

The above information is to the best of my knowledge true and correct ––>

I have read the Naturally Chiropractic Privacy Policies, the Consent for Care & Data Collection and the Expectations of Healing pages. ––––––––>

Having read these documents,
I confirm that I wish to proceed with care at Naturally Chiropractic. ——->

Please confirm

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