FEMALE TEENAGE HISTORY FORM
NEW PATIENT/ UPDATING PATIENT
INFORMATION
Date:______________
Name ___________________________ Date of Birth __ __ / __ __ / __ __ __ __ Age _______________
Parents/Guardians name/s _________________________________________________________________________
Main Address___________________________________________________________________________________________
Phone numbers: Home:______________ Mobile:_________________ Emergency No: ____________________
GP name and clinic_________________________________________Phone:___________________________________
School name:_______________________________________________ Phone: __________________________________
Do we have permission to contact your GP/school if needed? □Yes □No
Have you/your child ever received chiropractic care? □Yes □No
If so, when was the last visit ___________________________________________________________________________
Names of siblings:
Have they had previous Chiropractic Care?
____________________________D.O.B: ___/____/____ Age: ______
Yes/ No
____________________________D.O.B: ___/____/____ Age: ______
Yes/ No
____________________________D.O.B: ___/____/____ Age: ______
Yes/ No
____________________________D.O.B: ___/____/____ Age: ______
Yes/ No
____________________________D.O.B: ___/____/____ Age: ______
Yes/ No
Please tick the purpose of your/your child’s visit: □ maximizing normal growth and
development through wellness care □ symptomatic care (Neck Pain/Back Pain etc)
Today I/my child is attending for…
□ maximizing normal growth and development through wellness care
□ symptomatic care (Neck Pain/Back Pain etc) PTO
□ other
________________________________________________________________________________________
The summation of small traumatic forces over time can lead to damage.
The summation of positive changes over time can lead to brilliance.
Present Health Concerns:
What concerns do you have regarding your/your child’s health?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Does this concern interfere with Sleep? □Yes □No,
Eating □Yes □No
Daily Routine □Yes □No
Please tick the following if you/your child has or has had any of the following?
□ headaches/migraine
□ fevers
□ dizziness
□ irritability □ dental problems
□ depression/anxiety(tears or anger)
□ fatigue
□ constipation □ diarrhoea
hyperactivity □ attention difficulties □ social problems □ ear aches/ infections □
concentration problems
□ learning difficulties
□ recurrent cold/flu
□ behavioural problems
□ asthma
□ allergies
□ lower back pain □ mid-back pain
□ adenoid problems □ convulsions
□ seem uncoordinated/ clumsy
□ poor appetite □ chronic fatigue
□ neck pain
□ growing pains
□ joint problems
□ scoliosis □ recurrent chest infection
□ recurrent tonsillitis □ongoing “burping”, “flatulence”
□ Vaccinations up to date
Medical History:
Name:
Dosage:
What:
When (roughly):
Medications/ Supplements
Previous accidents and/or
injuries ie: motor vehicle
work- related or other:
Illnesses:
Surgeries:
□
Psychosocial History
Do you smoke?
Do you drink alcohol? Coffee? Coke? Other caffeinated drinks (eg. V, red bull, etc)
How much water do you drink per day?
How often do you eat at McDonalds or the like?
Do you use recreational drugs?
Do you exercise or play sport?
Have you started menstruating? How old were you when it started?
How often do you menstruate?
Have you engaged in sexual intercourse? If yes did you use contraception?
Are you on the contraceptive Pill?
Are you concerned about your weight?
Are you concerned about your appearance?
On a scale of 1-10 please rate your:
Eating Habits:
0
1
2
3
4
5
6
7
8
9
Poor
10
Excellent
Sleeping Habits
0
1
2
3
4
5
6
7
8
9
Poor
10
Excellent
Home Life
0
1
2
3
4
5
6
7
8
9
Poor
10
Excellent
School
0
1
2
3
4
5
6
7
8
9
Poor
10
Excellent
Happiness
0
1
2
3
4
5
6
7
8
9
Poor
10
Excellent
Family Health History
Please note any health problems that are present in:
( ie: cancer, scoliosis, gut issues, diabetes, heart conditions, respiratory conditions, allergies.)
Mothers family _____________________________________________________________
Fathers family _______________________________________________________________
Siblings ______________________________________________________________________
Parent or Guardian to fill out form from this point on please.
Pre-Natal History
Did you experience a happy, healthy & supportive pregnancy?
□Yes □No
If no, please explain ____________________________________________________________________________________
____________________________________________________________________________________________________________
Was your birthing experience free of complications?
□Yes □No
If no, please explain ____________________________________________________________________________________
____________________________________________________________________________________________________________
About the Birth
Duration of Labour:
_______________hours
Were medications or epidurals given to mother during labour? □No
What type?
□nitrous oxide gas
□pethidine
□Yes
□epidural
At birth, what was the child’s:
birth weight __________(gr/ Lbs:Oz)
head circumference______ (cm)
length________________(cm)
APGAR score
at birth ______/10
after 5 minutes _____ /10
Was your child breast fed? □ breastfed □ bottlefed □ expressed milk/formula
Is there anything else we need to know about the birth?
(eg head shape or other concerns)
____________________________________________________________________________________________________________
Post Natal History
Did your child have any anomalies after birth? (eg. hip issues, flattening of skull, birthmarks)
____________________________________________________________________________________________________________
Has your child had any illnesses? _____________________________________________________________________
Does your child suffer from allergies/ intolerances/ sensitivities?_________________________________
____________________________________________________________________________________________________________
Is your child on or have they been on any medications? ____________________________________________
How many courses? ____________________________________________________________________________________
Has your child been hospitalised or had surgery? ___________________________________________________
____________________________________________________________________________________________________________
Has your child had any traumas, broken bones or falls? ____________________________________________
____________________________________________________________________________________________________________
Chemical Stressors
At was age was the following introduced?: formula______________ cow’s milk__________________
solid foods ______________ What foods were introduced first? ________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
How often does your child receive dairy, processed foods, white sugar, gluten (flour) in their
diet? □never □ on weekends □ a few times per week □ daily □ nearly each meal
□ rarely
Are you aware of the impact of nutrition on children’s behaviour ? □Yes □No
Psychosocial Health
Any problems bonding? □No □Yes
Any behavioural problems? □No □Yes
Any hyperactivity or restlessness? □No □Yes
Any difficulties at daycare or school? □No □Yes □ N/A
Any night terrors, sleep walking, difficulty sleeping? □No □Yes
Prolonged temper tantrums or separation anxiety? □No □Yes
Growth and Development
At approximately what age did your child:
follow an object __________ hold head up __________ roll_________
vocalize in attempt to communicate __________ sit unassisted______ crawl ______ walk _______
Do you consider your child’s sleeping pattern normal □Yes □No
How many hours per day? ________
INFORMED CONSENT TO CHIROPRACTIC CARE
Chiropractic care is recognized as being an effective and safe method of care for many conditions.
However, changes to the law now require all chiropractors to warn people of material risks.
As in all health care, there are some risks with chiropractic care. This includes, but is not limited
to:
Your condition becoming worse;
 Disc injuries, rib fracture, sprains/strains (1 in 139,000 in the neck and 1 in 62,000 in the low back);
 Stroke or stroke like symptoms (1 in 5.85 million neck adjustments)
 Put in context, chiropractic has been shown to be 250 times safer than anti-inflammatory drugs and
safer than driving a car.
Some people may experience some mild soreness for 24-48 hours after their adjustments,
especially when their body is unwinding. This is a normal sign of change, as may occur after
exercise or stretching.
Clinical experience consistently demonstrates unexpected improvement in people’s life. One
study indicated that 23% of people experience improvement in some other aspect of their
health. Of individuals who experience such improvements:




26% experienced improvements in their respiratory system;
25% in their digestive system
14%circulatory system/heart;
14%eyes/vision.
Paediatric Chiropractic Care. I agree to the Chiropractors at the Umina Chiropractic Centre
delivering chiropractic care to minors under my care at my instruction. I understand that these
chiropractors are not paediatricians; but are qualified to manage chiropractic care in children. I
am also aware that these same chiropractors are members of the Chiropractors Association of
Australia and are registered health care practitioners under the AHPRA (Australian Health
Practitioners Regulatory Authority). The practitioners maintain their competencies by continuing
professional development.
Consent to Chiropractic Care. I do not expect the chiropractor to be able to anticipate or explain
all the risks and complications. I wish to rely on the chiropractor to exercise his/her judgement
during the course of procedures which he/she feels at the time, based upon the information
known, is in my best interests.
I understand that the intent of chiropractic care is to assist me in achieving my fullest potential. I
also understand that maintenance or wellness care does not rely on the presence of symptoms for
its application and monitoring have, to the best of my knowledge, provided, the chiropractor with
a complete and accurate health history. I have read the above consent. I have had the
opportunity to discuss with the chiropractor the nature and purpose of chiropractic adjustments
and other procedures as well as other concerns. I understand that results are not guaranteed. I
intend this consent form to cover the entire course of my chiropractic care for this and any future
presentation.
I hereby request and consent to chiropractic examinations, adjustments and other chiropractic
procedures wherever the chiropractor determines necessary. By signing below I agree to
chiropractic care.
Signature of Patient:______________________Print Patients name here:__________________________
(or parent if under 18 )
Parents name if applicable:_______________________ Date:___________________________________
Chiropractor’s signature:__________________________ Date:___________________________________