Childs first name*
Surname*
Date of birth
Age
Address
Town
Postcode
Parents names*
Contact numbers
Day
Evening
Mobile
Email address*
Preferred contact method?
Please choose...
Telephone
Email
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?
Pregnancy
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
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?
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
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?
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:
headaches
ear infections
concentration issues
sore throat
tonsilitis
hoarse voice
swallowing
jaw pain or clicking
neck pain
asthma
conjunctivitis
Wind
sight problems
hearing problems
Sinus problems
stomach aches
growing pains
epilepsy or fits
diarrhoea
constipation
fainting
fatigue
rashes
loss of consciousness
Activities
Are they
clumsy
coordinated
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.
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 child_history 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.