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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*
Date of birth
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.
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?
for how long
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?
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:
Any other reactions?
Are/were they breast fed
Does/did mum suffer from any discomfort, breast or nipple problems?
Do/did they feed better to one side
Which side ?
Do they feed efficiently and well?
Do they suffer any food allergies or intolerances?
How often do they fill their nappies?
What colour is it when they do?
Do they struggle to poo or pass wind?
Do they sleep well?
Are they swaddled?
Do they sleep on their:
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:
Do they play sports?
If yes, please describe
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. ——->
Naturally Chiropractic: 1a St Oswins Place, Tynemouth NE30 4RQ
t: 0191 259 6777 | e: email@example.com
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