Tynemouth's premier chiropractic care facility
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New Patient history: Children
Please fill in as much of this form as you can and tick where appropriate.
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.

Areas marked with * must be filled in.
To use this form you must enter a valid email address.
Can we check that you have read these pages:

Privacy Policies
Consent for Care & Data Collection
Expectations of Healing 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.
Childs first name*
Date of birth
Parents names*
Contact numbers
Email address*
Preferred contact method?
Name of GP
Has your child ever had chiropractic care?
Yes No
Why are you bringing your child to the clinic?
How did you hear about Naturally Chiropractic?
Did your pregnancy
go to full term?
yes no
for how long
Please describe any problems you had during your pregnancy, however minor
Did you have any ultrasound scans?
yes no
how many
how long did they last?
Did you have other tests (e.g. amniocentesis?)
yes no
If yes, please list
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 intervention? (e.g. forceps, ventouse)

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

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

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:
Ear infections
sleeping difficulties
eating difficulties
Swelling at injection site
Autism or learning difficulties
Any other reactions?
Are/were they breast fed
yes no
for how long
Does/did mum suffer from any discomfort,
breast or nipple problems?
yes no
Please describe
Do/did they feed better to one side
yes no
which side
Do they feed efficiently and well?
yes no

Please describe
Do they suffer any food allergies or intolerances?
yes no

Please describe
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?

yes no

Are they swaddled?

yes no

Do they sleep on their

front back side

General health
Have they had any hospitalisations?
yes no
Please describe
Have they had any childhood illnesses?
yes no
Please describe
Do they suffer from any of the following? If yes, please tick boxes:
ear infections
concentration issues
sore throat
hoarse voice
jaw pain or clicking
neck pain
sight problems
hearing problems
Sinus problems
stomach aches
growing pains
epilepsy or fits
loss of consciousness
Are they
Do they play sports
yes no
If yes, please describe
Reason for visit
Please describe any current health issues
or concerns
Thank you for taking the time to fill in this form. Please acknowledge the ALL following declarations. If you don't, we cannot accept you as a patient.
Declaration* 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 for my child at Naturally Chiropractic.
Parent or guardians full name:
Relationship to child Date
*Access code: please type natchiro-child in the box.
This so we know you are human.
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.
Naturally Chiropractic: 1a St Oswins Place, Tynemouth NE30 4RQ0191 259 6777 • info@naturallychiropractic.co.uk PRIVACY HOME