Child Patient Form - Restoring Health Chiropractic

Personal Details
Name *
Today's Date
Parent/s Names *
Parent's marital status *
Who does child live with? *
Address *
Emergency Contact Name & No. *
Who can we thank for referring you
Age *
Date of birth *
Gender *

M F
Sports, Hobbies, Activities *
Current Health Information

Information about your birth
Your Birth Process *

Difficult Forceps Suction Caps Caesarean Use of Drugs Normal
Weight at Birth *
Was mum smoking during pregnancy? *

Yes No
Was mum drinking during pregnancy? *

Yes No
Was dad smoking during pregnancy? *

Yes No
Was dad drinking during pregnancy? *

Yes No
What brings you here today? *
Please provide details if you have / had any of the following
Breast fed both sides *

Yes No
Genetic abnormalities
Serious falls or accidents
Sports injuries
Concussion
Motor vehicle accident
Fractured / broken bones
Torn ligaments / muscles
Operations
Weight problem
Poor sleep
Irritable bowel syndrome: diarrhoea / constipation *

Yes No
Colic *

Yes No
Ear infections *

Yes No
Poor concentration *

Yes No
Poor balance *

Yes No
Poor attention *

Yes No
Growing pains *

Yes No
Headaches *

Yes No
Mood swings *

Yes No
Anxiety *

Yes No
Learning difficulties *

Yes No
Reaction to vaccination *

Yes No
Bed wetting
Medications - if yes, please list
Vitamins - if yes, please list
Any other health conditions
Email Address *
The statements made on this form are accurate and I agree to allow this office to do an examination of me for further evaluation and hereby authorize the chiropractor to discuss details of my case with any other doctor as is appropriate in confidence. *

Yes
Name of parent/guardian who has completed the form. Please note, clicking "Submit to Reception" constitutes acceptance of the foregoing statement. *

51 Moxhams Road

(02) 8677 0443

Child - New Patient Form

Please complete and submit

Personal Details

Current Health Information

Please provide details if you have / had any of the following

We believe in the bodies ability to heal itself.