Childs first name*
Date of birth
Preferred contact method?
Name of GP
Has your child ever had chiropractic care?
Why are you bringing your child to the clinic?
How did you hear about Naturally Chiropractic?
Did your pregnancy
go to full term?
for how long
Please describe any problems you had during your pregnancy, however minor
Did you have any ultrasound scans?
how long did they last?
Did you have other tests (e.g. amniocentesis?)
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:
Swelling at injection site
Autism or learning difficulties
Any other reactions?
Are/were they breast fed
for how long
Does/did mum suffer from any discomfort,
breast or nipple problems?
Do/did they feed better to one 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
front back side
Have they had any hospitalisations?
Have they had any childhood illnesses?
Do they suffer from any of the following? If yes, please tick boxes:
jaw pain or clicking
epilepsy or fits
loss of consciousness
Do they play sports
If yes, please describe
Reason for visit
Please describe any current health issues
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
*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.