“Optimal Health through Progressive Chiropractic Care”
CHILDREN’S HEALTH QUESTIONAIRE
Dear Parent/Guardian,
It is our pleasure to welcome you to our clinic. Please carefully complete the following questionnaire. Your
answers will help us to determine how chiropractic may benefit your child. Thank you.
Child’s First Name:
Date of Birth:
/
Child’s Surname:
/
Age:
Gender: M / F
Mother’s Name:
Father’s Name:
Address:
Postcode:
Postal Address:
Postcode:
Telephone - Home:
Mobile:
Work:
Email:
Other Children’s Names:
Have they previously had a Chiropractic examination?
D.O.B.:
/
/
Age:
Yes / No
D.O.B.:
/
/
Age:
Yes / No
D.O.B.:
/
/
Age:
Yes / No
How did you find out about Mid-Murray Chiropractic? (Please tick)
 Yellow Pages
 Internet
 Advertising
 Signage
 Relative/Friend (Name:
HEALTH HISTORY
What concerns do you have regarding the health of your child?
Original onset date:
Caused by:
Has your child visited your local Maternal and Child Health Centre (M&CH)?
Yes / No
Have any concerns regarding your child been raised by M&CH?
Yes / No
If yes, please describe:
Has your child ever had any of the following? (Please describe)
Been hospitalised or had surgery?
Major / Serious illness?
Broken bones or strain/sprain injuries?
Been involved in a motor vehicle accident?
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)
Has your child ever been involved in a motor vehicle accident?
Yes / No
Has your child ever had any significant falls?
Yes / No
Is your child accident prone?
Yes / No
Has your child received Chiropractic care before?
Yes / No
Reason for care?
Date of last visit:
/
Were x-rays taken?
/
Name of Chiropractor / Clinic:
Yes / No
Would you describe the care as:  Excellent  Good  Fair
 Poor
PREGNANCY
Naturally conceived?
Yes / No
Morning sickness?
Yes / No
Did you require any medication through your pregnancy?
Yes / No
Were there any complications through your pregnancy?
Yes / No
Please explain:
LABOUR AND BIRTH
The birth of your child can give vital clues as to potential spinal problems. Please answer the following questions
about the labour and the birth of your child.
Birth Mother’s age at date of baby’s birth:
Drugs during labour / birth?
Yes / No
Vaginal birth?
Yes / No
Delivered normally?
Yes / No
Breech presentation?
Yes / No
Posterior?
Yes / No
Premature
Yes / No
At term?
Yes / No
Caesarian?
Yes / No
Overdue / Late?
Yes / No
Forceps / Suction?
Yes / No
Chemically induced?
Yes / No
Doctor’s hands on?
Yes / No
Other:
Birth Weight:
APGAR Scores: (1min)
How long were you in labour?
Was a family member there?
(5 min)
How long did you “push” for?
hrs
Yes / No
If yes, who?
Do you believe the birth was stressful for your child?
Yes / No
Was your child’s head mis-shapen at birth?
Yes / No
Were there any delivery complications?
Yes / No
Please describe:
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min/hrs
YOUR CHILD’S FIRST YEAR
Was your child breast fed?
Yes / No
For how long?
Were there attachment issues?
Yes / No
Details:
Was your child formula fed?
Yes / No
For how long?
Did your child suffer with colic?
Yes / No
If yes, was it: Mild / Moderate / Severe
Did your child suffer with reflux?
Yes / No
If yes, was it: Mild / Moderate / Severe
Type:
Would you say your child was a:
 Very poor sleeper
 Poor sleeper
 Average sleeper
At what age did your child begin crawling?
 Good sleeper
 Very good sleeper
How long did s/he crawl for?
CURRENT CONCERNS
Please tick any of the following conditions which your child has experienced (??)in the past six months:
General
 Neck Pain
 Back Pain
 Constipation / Diarrhoea
 Headaches
 Bedwetting
 Rashes
 Growing Pains
 Loss of Appetite
 Visual Disorders
 Constant Fatigue
 Arm / Leg Pain
 Scoliosis / Poor Posture
 Joint Pains
 Hip Problems
 Extremely messy eater
 Bloody Noses
 Poor co-ordination / clumsiness
Social Behaviour
 Hyperactivity
 Night Terrors
 Poor sleeping habits
 Developmental delay
 Poor social skills
 Delayed verbal communication
 Behavioural issues
 Learning difficulties
 Diagnosed as ADD/ ADHD
 Diagnosis of Autism
 Difficulty with reading/writing/spelling
Illnesses
 Sinus Problems
 Allergies
 Earaches / Infections
 Recurrent tonsillitis
 Digestive Disorders
 Recurrent Chest Infections
 Convulsions
 Asthma
 Recurrent stomach aches
 Seizures / Convulsions
 Travel Sickness
 Chronic Colds
 Recurring Fevers
Other:
Is your child taking any vitamins, supplements, or medication? Please describe:
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If you could improve one aspect of your child’s behaviour, what would it be?
Is your child vaccinated?
Yes / No
Reactions?
Has your child ever been assessed for the presence of scoliosis?
Yes / No
Yes / No
How many times has your child taken antibiotics?
In the past six months:
During their lifetime:
Consent to Chiropractic Care
Chiropractic care is recognised as being an effective and safe form of healing. In fact, due to the wonderful results,
chiropractic is the largest drug-free health care profession in the world. However, you must recognise that there are risks
associated with any health care procedure, including assessment and treatment, which you should be informed about.
1.
2.
3.
4.
Very rare risks may include muscle and joint soreness, nausea and dizziness, strain/injury to a ligament or disc,
and/or aggravation of the underlying condition.
In extremely rare circumstances, some treatments of the neck may damage a blood vessel and lead to stroke or
related symptoms (current statistics eg between 1 in 2 million to 1 in 5.85 million-Haldeman, et al. Spine vol 24-8
1999). If any adjustments (manipulations) are required, you will be tested beforehand.
You will have the opportunity to discuss your proposed care with the chiropractor and ask any questions before
any care is given.
Chiropractic adjustments of the spine are internationally recognised as being far safer in dealing with neck and low
back pain than medication and many other alternatives. (A Risk Assessment of Cervical Manipulation, JMPT, 1995.
Magna Report, Ontario Ministry of Health, 1993.)
I acknowledge the above information and realize that there is a degree of variation in individual patient response.
Based on all the information provided, I consent to and look forward to receiving Chiropractic care at this office.
Parent / Guardian Signature
Date
Patient’s Name
Chiropractor’s Signature
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