CONFIDENTIAL CHILD PATIENT HISTORY FORM 4 - 12 YEARS
First Name:
Surname:
Age
Date of Birth:
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Street:
Suburb:
State:
Parentt’s Name:
(PH):
Postcode:
(M):
Parent’s Email:
Has child been to a chiropractor before?
When was the last treatment?
Yes / No
Who referred you to this clinic?
Private Health Fund:
What is the main reason for attending this chiropractic clinic?
Has your child had any form of treatment for this complaint before?
Age of siblings?
Immunised? Yes / No Allergies?
Premature?
Yes / No
Problems requiring treatment at birth?
Problems during pregnancy?
Type of delivery?
Head shape at birth? Normal / Asymmetric
Normal / Breech / Forceps / Caesarean / Suction
Developmental concerns?
Yes / No
Temperament as baby?
Happy easy baby
Hand dominance:
Left / Right
Foot dominance:
Left / Right
Age Crawling?
Age Walking?
/ poor sleeper / colicky / unsettled /
Eye dominance:
Left / Right
cried a lot
Ear Dominance:
Left / Right
GENERAL HEALTH:
Have you noticed your child has problems with any of the following: Please circle:
Headaches / Fever / Irritability
Hearing / Ear problems / Infections
Eye problems
Nose / Sinus / Hayfever / Allergies
New or recurrent cough
Mouth problems / Throat Infections
Asthma / Respiratory infections / Breathing problems
Bones or Joint pain / Growth and development / Clicky hips
Orthotics
Muscle Control / Lack of muscle tone / Balance and Co-ordination
Other comments:
Skin conditions / Rash
Lumps / Swelling / Bruising
Vomitting / Digesting food / Colic
Diarrhoea / Constipation / Reflux
Gastrointestinal / Abdominal discomfort
Genital or Urinary Problems / Bedwetting
Heart Problems
Seizures / Head banging
Psychological / Behavioural / Attention
Sensory integration/ Learning concerns
Does your child participate in any sports or hobbies?
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When was their last visit to the doctor? Please give details:
Is your child taking any medication or nutritional supplements? Please list:
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Has your child ever been to hospital, had any major bumps/falls or surgery? Please give details:
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Has your child fractured, broken or dislocated any part of their body? Please give details:
…………………………………………………………………………………………………………………….
Have you had an X-ray, CT scan, Ultrasound, MRI or other scan? Please give details:
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Family History? Please circle
Stroke
Cancer
Diabetes
Heart Problems
Migraine
PATIENT INFORMATION PRIOR TO TREATMENT
Changes to the law now require all practitioners who manipulate the spine to warn patients of the
material risks. In extreme rare circumstances, it is possible to exacerbate a condition. All
techniques employed are gentle and safe, and manipulations on children are provided with extreme
care.
Chiropractic adjustments (manipulation) of the spine are internationally recognized 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. Manga Report, Ontario Ministry of Health,
1993).
If you have any questions relating to the treatment your child is about to receive, please speak to
the chiropractor. The law requires consent to treatment from both parents. By signing below, you
have agreed there is consent from both parents.
Please sign below if you understand the above information.
Parent / Guardian signature:
………………………………………………………
Date:
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