NAME OF YOUR CENTER HERE

YOUR NAME HERE

YOUR ADDRESS HERE

YOUR PHONE NUMBER HERE

Children’s Re-Evaluation Survey

Child’s Name______Age ______Name of Parent/Guardian______

  1. My child is (aware, not aware) of changes in how they carry their body. They are: ______
  2. My child is (more, same, less) aware of breathing when being adjusted.
  3. My child is (more, same, less) aware of breathing in between adjusting session.
  4. In general, my child’s breathing is (deeper, same, more shallow) and (easier, same, more difficult.)
  5. In general, my child’s movement is (easier, same, more difficult.)
  6. In general, my child (has, does not have) greater ease in standing straighter.

Physical Stresses

Has the child had any new:Falls Car accidents Sport injuries Broken bones Other ______

Is your child involved in any new athletic activities or extra-curricular activities? Yes or No

Do/did you notice any position in which your child seems uncomfortable? Yes or No

Comments ______

______

Emotional/Mental Stresses:Please circle any of the following emotional/mental stresses that the child has experienced:

Illness Parent’s divorce School Abuse Loss of loved one Family other ______

Comments______

______

Chemical Stresses

Is your child currently taking any medication? Yes or No Please Explain______

Has your child reduced any medications? Yes or No Please Explain______

Comments ______

______

Is there any new information about your child’s health that you would like to share with us?

______

______

Do you have any concerns that you feel you would like to discuss?______

______

Have there been any expected or unexpected reactions since your child’s last evaluation? Yes ___ No ___

Have there been any slips, falls, accidents or change in your condition since your child’s last evaluation

Yes _____ No ____ If yes, please explain: ______

Is there anything you would like to connect about since your child’s last evaluation? Yes ____ No _____

If yes please explain: ____________

For Office use Evaluation Record: TYPE: Level: I II III PE RE RESCAN ANIV Other______

PRACTICE MEMBER COMMENTS: ______

______

INSTRUMENTATION: Tech NONE N/A PHOTO EMG THERM ROM X-RAY REGION:

Additional interpretation: ______

PHYSICAL/SPINAL EVALUATION: NONE N/A ON CHART ON OUTCOME ASSESMENT

Additional Comments: ______

______

RECOMMENDATIONS: LEVEL: Basic IntermediateAdvanced Wellness

Freq: ____ / week month for ______/week month for ___ next eval: PE/RE ____ PE/RE ____ PE/RE ____ PE/RE ____

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