Welcome to the Café of Life – Child Forms
Name of Child___________________________________Middle initial:___ Date_________________
Address_________________________________________ City______________ Province____
Postal Code______________ Date of Birth: D___ M ___ Y _______ Age _______
Home
Phone _______________ E-mail _____________________
Parents
/ Guardians___________________________________
Work Phone________________
Has
your child ever been adjusted by a chiropractor?
¨
Yes ¨
No
Child’s Birth History
1. What was the child’s gestational age at birth? ____________ weeks
2. Birth Weight _________ Birth length __________
3. Was your child’s birth: ¨ At Home ¨ Birthing Centre ¨ Hospital
4. Who was the primary caregiver? ¨ OB/GYN ¨ Midwife
5. What was the duration of the labor and birth? ___________
6. APGAR score: At birth: ____/10 After 5 minutes ______/10
7. Was the birth (check all that apply) ¨ drug induced ¨ forceps or suction
¨ “C” section ¨ cord around the neck
¨ breech ¨ prolonged
¨ natural (absolutely no medical intervention) ¨ other: ______________________
8. Were medications or epidurals given to the mother during birth? ¨ Yes ¨ No
9. Describe any other physical or mechanical stress to the mother or infant as labour progressed
and delivery progressed. ___________________________________________________________________________
10. Was the child born: ¨ Cephalic (head first) ¨ Breech (feet first)
11. Was there any evidence of birth trauma to the infant?
(Please check)
¨ bruising ¨ marks on face
¨ stuck in birth canal ¨ lack of arm or leg movement
¨ respiratory distress ¨ odd shaped head
¨ cord around neck ¨ fast or excessively long birth
Prenatal Maternal History
12. Where the mother under chiropractic care during pregnancy? Yes ¨ No ¨
13.Was the mother outwardly ill prior to her pregnancy ? ¨ Yes ¨ No
14. Were there any illnesses during the pregnancy? ¨ Yes ¨ No
15. Did the mother have a difficult pregnancy? ¨ Yes ¨ No
If yes, please explain ____________________________________________________________
16. Did the mother have any falls, accidents or physical injuries during the pregnancy?
¨ Yes ¨ No
If yes, please explain ____________________________________________________________
17. During pregnancy, did the mother: Smoke ¨ Yes ¨ No If yes, how much? __________
Drink ¨ Yes ¨ No If yes, how much? __________
18. Were there any supplements taken during pregnancy? ¨ Yes ¨ No
If yes, please explain ____________________________________________________________
19. Were there any drugs/medications taken during pregnancy? ¨ Yes ¨ No
If yes, please explain ____________________________________________________________
20. Were there any ultrasounds during pregnancy? ¨ Yes ¨ No
If yes, how many?_____ Reasons for being done? ____________________________________
21. Were there any invasive procedures during pregnancy? (amniocentesis, CVS, etc)
¨ Yes ¨ No
If yes, please explain ____________________________________________________________
Child’s Present Health
22. Are there any current concerns/ complaints?
If yes, please explain____________________________________
23. Does any current complaint interfere with: Sleep
¨
Yes ¨ No
Movement
¨
Yes ¨ No
Eating
¨ Yes
¨ No
Concentration ¨ Yes
¨
No
24. List any prescription drugs, over the counter drugs, vitamins and supplements currently being taken: _____________________________________________________________________________________
25. List any hospitalizations, surgical operations (indicate
year): __________________________________________
26. List any health care providers the child has seen (past
or present) ____________________________________
27.
In the first column write the number of average daily consumptions
of each product. In the second
column write the number of average weekly consumptions or each
product.
___ ___Water ___ ___Fast foods
___ ___Vitamins, # of
___ ___Cooked, canned
vegetables ___
___Chicken
___ ___Soft drinks, Diet ¨ ___ ___Raw vegetables
___ ___Fish/Seafood ___ ___Artificial Sweeteners
___ ___Cheese, yogurt, ice
cream ___
___Beef
___ ___Sweets / Candy ___ ___Eggs
___ ___Bread,
Type__________
___
___Medications, # of pills _____
___ ___Fruit
28. At what age did the child: Respond to sound: _______
Follow an object ________
Hold up head _______
Vocalize
________
Sit alone
_______
Teethe
________
Crawl
_______
Walk
________
29. Has the child reached all milestones at the appropriate
age?
¨
Yes ¨ No
30. If no, please explain_______________________________________________________
31. Do you consider the child’s sleeping pattern to be
normal?
¨ Yes
¨
No
32. If no, please explain_______________________________________________________
Physical History
33. Each of the following are causes of potential vertebral
subluxations.
34. Please circle the appropriate box, P = past, C = current, and the correct level of trauma:
Mild, Moderate or Extreme.
Mild
Moderate
Extreme
Falls from crib, carriage P C
P C
P C
Falls down steps
P C
P C
P C
Falls on ice P C
P C
P C
Sports impacts P C
P C
P C
35. Has the child had any traumas resulting in extensive bruising, cuts, stitches or fractures?
¨
Yes ¨ No
36. Has the child been in any motor vehicle accidents? ¨
Yes ¨ No
37. Please describe what happened and
when:_______________________________
38. Are any sports played?
____________________________________________________
39. Is a school backpack used? ¨ Yes
¨
No
40. Is the backpack: ¨Heavy ¨Med.
weight ¨ Light
41.
Was this child breast fed? ¨ Yes
¨
No If
yes, for how long? _____________
43.
42. Formula introduced at what age? ________
44.
Began solid foods at what age? _________
45.
Do they have any food/juice intolerances?
¨
Yes ¨
No
46.
If yes, please explain: _____________________________________________________
47.
Are there any pets at home? ¨ Yes
¨
No If yes, please list:
___________________
48.
Are there any smokers in the home? ¨ Yes
¨
No
49.
Have they taken any antibiotics?: ¨ Yes
¨
No If yes,
reason:__________________
50.
Vaccinations and age given: _______________________________________________
51.
Were there any side effects?
¨
Yes ¨
No
52.
If yes, please explain: ______________________________________________________
53.
Were there any difficulties with lactation?
¨ Yes
¨
No
54.
If yes, please explain: ______________________________________________________
55.
Were there any problems with bonding?
¨ Yes
¨
No
56.
If yes, please explain: ______________________________________________________
57.
Are there any behavioral problems?
¨ Yes
¨
No
58.
If yes, please explain: ______________________________________________________
59.
Are there any sleep disturbances? (Night terrors, sleep walking, difficulty
sleeping)
¨ Yes
¨
No
60.
If yes, please explain: ______________________________________________________
61. Age child began day care:
__________
62.
Average number of hours of television per week? ___________
63. Do you feel that your child’s social and emotional development is normal for their age?
¨
Yes ¨
No
64.
If no, please explain: ______________________________________________________