Child's
First Name _______________________ Last
Name _____________________________________
Address _______________________________________________________________________
City
___________________________ Province_____________
Postal Code________________________
Home
Phone _______________________ Email
address__________________________________
Health
Card No. ____________________________________
Version Code ___________________
Date
of Birth: D____ /M ______
/Y __________
Name of Parents ________________________________________________________________
Home
Phone___________ Business Phone____________
ext _______ Mobile Phone ___________
Other children? ?
No ?
Yes - Names (ages): _________________________________________
Name of additional caretaker(s)______________________________________________________
Emergency
contact _____________________________________
Phone____________________
Has
your family seen a chiropractor before? ?
No ?
Yes ?| If so, when? _____________________
Reason for seeking services at Café of Life:___________________________________________________
How did you find out about Café of Life? _______________________________________________
Is there anything about your child's nerve system and spine we should
know about? ________________
______________________________________________________________________________
What
is your level of commitment to you and your child's life and well-being?
?
High
?
Medium
?
Low
Additional Comments: _____________________________________________________________
______________________________________________________________________________
Thank
you for completing this more detailed questionnaire. All the information we collect is confidential and is
valuable in order for us to provide you with exceptional service. If you have any questions please ask the host or the
Chiropractor. Please inform the
host or the Chiropractor when you have completed this information.
First Name _____________________________ Last Name _____________________________________
Name of previous chiropractor and date of last visit? ______________________________________
Describe Experience _____________________________________________________________
Name of present MD/Pediatrician and address? _________________________________________
______________________________________________________________________________
Date and reason for last MD visit? ___________________________________________________
Does your child have any current health concerns? If yes, please describe and complete the following questions, if no move onto *_________________________________________________________________________
__________________________________________________________________________When did this/these health concern(s) begin? ___________________________________________________________
Have you sought advice or treatment from a health professional? ? Yes ? No
If yes, what were you told? _________________________________________________________
What was done?__________________________________ Did it seem to work? ? Yes ? No
Please indicate how this condition affects your child's daily function and the function of your family?___
______________________________________________________________________________
What concerns you about this situation? _______________________________________________
______________________________________________________________________________
Why do you think your child is experiencing this health event? _______________________________
______________________________________________________________________________
*What are your expectations of your chiropractic care at the Café of Life?_____________________
______________________________________________________________________________
To develop an understanding about Chiropractic, the body's healing ability, life force and the nervous system we request that you attend one of our special Wellness Lectures during your first month of your child's care. Are you willing to attend one of our seminars?
?Yes ? No ? Will consider
Family
and Personal History:
Please
list whether you or anyone in your close family has a history of any of the
following:
Cancer ________________________________________________________________________
Diabetes ______________________________________________________________________
Heart disease/high blood pressure _____________________________________________________
High cholesterol _________________________________________________________________
Any other health concerns _________________________________________________________
History
of pregnancy, labour and birth:
Name of Obstetrician/Midwife_______________________________________________________
Please list any medical or alternative, treatments or procedures done during pregnancy_____________
______________________________________________________________________________
Please list any drugs, herbs or supplements taken during pregnancy___________________________
______________________________________________________________________________
Please list any traumas to the mother during pregnancy (ie accidents, emotional)__________________
______________________________________________________________________________
Birth attendants (MD, Midwife, Doula)________________________________________________
Location of Birth_________________________________________________________________
Mother's position during labour (back side, sitting standing, other)____________________________
______________________________________________________________________________
Was labour induced? ? Yes ? No
Did the mother receive any drugs before during or after the birth process? (Epidural, Morphine, Other)_
Was an episiotomy performed? ? Yes ? No
Duration of labour________________________________________________________________
Duration of delivery (time spent in birth canal)___________________________________________
Birth Position? ? Cephalic (head first) ? Occiput Posterior (facing forward)
? Breech (feet first) ? Other_________________________________
Any assistance required during birth? (ie forceps, vacuum extraction, manual assistance, Cesarean)____
Any complications during or after birth? (ie stuck in birth canal, cord around neck)________________
______________________________________________________________________________
Any evidence of trauma during birth (ie bruises, marks)____________________________________
Was your child subjected to any procedures following birth?
? Silver Nitrate eye drops ? Incubation (how long?)___________________________________
? Vitamin K injection ? Separation from mother (how long?)_________________________
? Respiration ? Other_______________________________________________
Was your child alert and responsive within 12 hours of delivery? Explain_______________________
______________________________________________________________________________
What was the child's gestational age at birth?_______________________________________ weeks
Birth Weight _____________________________ Birth Length_____________________________
Congenital Anomalies or defects present?______________________________________________
Growth
and Development:
At
what age did your child:
Follow an object__________________________ Respond to Sound_______________________
Hold up head_____________________________ Sit unassisted___________________________
Vocalize_________________________________ Talk__________________________________
Teethe__________________________________ Crawl________________________________
Walk___________________________________ Run__________________________________
PHYSICAL
STRESSORS, activities, habits, traumas or challenges:
Please
list the details, treatments and age/date (as necessary) of past and present
PHYSICAL experiences:
Surgeries/Hospitalizations __________________________________________________________
Falls (ie from couches, beds, change table) and accidents___________________________________
______________________________________________________________________________
Traumas resulting in bruises, fractures or stitches_________________________________________
______________________________________________________________________________
Car Accidents (describe)___________________________________________________________
Other Past or Current Illness/Infection ________________________________________________
How much (and what kind of) exercise does your child get?_________________________________
______________________________________________________________________________
Is a school backpack used? ? No ? Yes (Heavy) ? Yes (Light)
Other _________________________________________________________________________
CHEMICAL
STRESSORS, activities, habits, traumas or challenges:
Please
indicate present and past exposures during pregnancy to (per day/week):
Cigarette Smoke ________________________________________________________________
Alcohol/Caffeine ________________________________________________________________
Supplements: ___________________________________________________________________
Medications/procedures (ie amniocentesis, ultrasound) ____________________________________
Was
your child breastfed? ?
No
?
Yes (until what age?)__________________________
Introduced
to formula? ?
No
?
Yes (at what age?)____________________________
Introduced
to cows milk? ?
No
?
Yes (at what age?)____________________________
Solid foods at what age?___________________________________________________________
Please list your child's history of antibiotic use and types___________________________________
______________________________________________________________________________
Please list your child's history of vaccinations and the age given______________________________
______________________________________________________________________________
Reason for vaccinations?___________________________________________________________
Any adverse reactions?____________________________________________________________
Any smokers in the home?__________________________________________________________
Any pets in the home?_____________________________________________________________
What are your child's typical daily food choices:
Breakfast: _____________________________________________________________________
Lunch: ________________________________________________________________________
Dinner: ________________________________________________________________________
Snacks: _______________________________________________________________________
What is your child's daily fluid intake? How many glasses of:
Water_____________ Juice______________ Pop______________ Dairy___________________
Other_________________________________________
EMOTIONAL/MENTAL
STRESSORS activities, habits, traumas or challenges:
Any problems with lactation and/or feeding?____________________________________________
______________________________________________________________________________
Any problems with bonding with your child?____________________________________________
Any behavioral problems?_________________________________________________________
Any emotional traumas? (ie death in family, abuse, school)__________________________________
Does your child sleep through the night? ? Yes ? No Sleeping Position?___________________
How many hours does your child sleep a night?______________ Quality?______________________
Any night terrors, sleep walking, bedwetting or difficulty sleeping?____________________________
______________________________________________________________________________
How many hours per week does your child watch television? _______________________________
Approximate hours of playtime per week_______________________________________________
Do you feel that your child's physical, social and emotional development is normal for their age? (Please explain)