A Well Adjusted Clinic

Chiropractic and Massage

Child Initial Consultation form (0-8yrs) Date:______

First Name: ______Surname:______DOB: ______Age: ______

Address: ______

______Post code: ______

Mum’s Name:______Phone(M)______(H)______

Dad’s Name:______Phone(M)______(H) ______

Other siblings: ______

How did you hear about us? ______Health Fund:Y/ N ______

Regular medical doctor & location: ______

Previous chiropractic care(name & location, response, date of last visit): ______

What concerns do you have about their health (purpose for today's visit)? ______

How long has this been a problem for?______

Has anyone else in the family had this problem?______

What seems to make it better? ______

What seems to make it worse? ______

Have you had any treatments for this? ______

Your health history:

Did you have any problems during pregnancy? Y / N Details:______

Did you have any: serious illnesses / traumas / stress / antibiotic use / medications required

Where there many tests conducted through pregnancy? ______

How are you and your family coping with your childs health concerns? ______

Your Childs Health History:

Tell me about their delivery (how many weeks gestation, type of birth, drugs used, APGAR score etc) ______

______

Birth weight: ______birth length:______Length of labour: ______

Complications during delivery or shortly after: ______

How do you feel about their delivery? ______

Did they have trouble feeding (either breast or bottle, poor suck, nipple shield): ______

Unsettled/colicky ? Y / N Do they sleep well? Y / N Regular sickness? Y/N

Are you concerned about their learning and development? Y/N ______

When did they roll over: ______Crawling age(type of crawl): ______

Walking age: ______When did they say their first word: ______

Have they needed medical treatment for anything? ______

Please circle if your child has had any of the following:

Headaches / Tonsillitis / Ear infections
asthma / allergies / eczema
neck pain / travel sickness / growing pains
back pain / shoulder/wrist pain / hip/knee/ankle pain
numbness / tingling / sudden weight change
hyperactivity / stomach aches / learning difficulties
visual changes / hearing issues / sleep problems
temper tantrums / seizures/fits / recurring fevers
bed wetting / colic/reflux / scoliosis
ADHD / digestive problems / chronic colds
diabetes / muscle disorders / stress/anxiety

Medical History:

Is your child currently taking any medication? Y / N Details:______

Any surgeries or hospitalisations? ______

Any broken bones or dislocations? ______

Is your child accident prone? ______

Has your child had any significant falls or accidents? ______

Suffered any diseases or illnesses? Y / N Details: ______

Have they had a recent infection, fever, chills, lethargic, vomiting, rash, diarrhoea? Y / N Details: ______

Has your child ever been assessed for scoliosis? Y / N

The human body is designed to be healthy. Throughout life, events occur that can damage how your nervous system functions, and may result in poor or declining health. In bringing your child to A Well Adjusted Clinic, you consent to being responsible for making and keeping appointments and for paying the costs or treatments. It is the policy of this clinic that all accounts are settled on the day of consultation. Let’s work together for happier, healthier children.

Last Minute Cancellations: Please be considerate of other people! Giving our reception staff late notice of appointment cancellations prevents other people receiving the treatment they need. The following charges may apply to late notice cancellations:

Day of appointment: $15

Less than 2 hours notice: $20

No show: Full Fee

Patients Name: ______Date: ______

Guardians Name: ______Signature: ______