Child Clinical Information Form
It surprises many people when they discover chiropractic doctors don’t treat symptoms; instead, they find the underlying cause(s) of your ache, pain or condition, and help your body to heal. Chiropractors understand that symptoms may indicate that there is something not functioning correctly in the body, or they may be good warning signs from an optimally functioning body that is being overstressed. If your child is experiencing symptoms, then please describe these as fully and informatively as you can by answering the following:
What is your name (Parent or Carer)? *
Your answer
What is your child's name? *
Your answer
What is the main concern or symptom? *
Your answer
When did this pain/problem start?
MM
/
DD
/
YYYY
What (if anything) triggered the pain/problem?
Your answer
Birth
The birth of your child can give vital clues as to potential spinal problems. Please answer the following questions very carefully
Was your child delivered
Birth weight
Your answer
APGAR Scores
Your answer
If you are aware; how long was the mother in labour?
Your answer
How long did you 'push' for?
minutes/hours
Your answer
Do you believe the birth was traumatic for the child?
Was your child's head misshapen at birth?
Were there any delivery complication?
If yes, please give some detail
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Cloud Concepts. Report Abuse - Terms of Service - Additional Terms