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#204, 1740 Gordon Drive ♦ Kelowna, BC ♦ V1Y 3H2 ♦ 250-868-4880 www.lifeworkschiropractic.ca [email protected]
Patient Introduction – Child & Adolescent Personal History:
Your Name: __________________________________________________________ First (Nick-name) Last
Your Mom: _____________________ Your Dad: _____________________
Sibling: _____________________ Sibling: _____________________
Sibling: _____________________ Sibling: _____________________
Your Mailing Address (including postal code please): _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Telephone: Home: Mom’s cell: ____________________
Dad’ s cell: Email: ________________________________
Birth Date: Day: Month: Year: ____________
Previous Chiropractor: City: _______________
Last visit to this Chiropractor: __________________________________________
Reason for leaving: _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Present MD: City: _______________
Referred to our Centre by: _____________________________________________
#204, 1740 Gordon Drive ♦ Kelowna, BC ♦ V1Y 3H2 ♦ 250-868-4880 www.lifeworkschiropractic.ca [email protected]
Initial Child & Adolescent Questionnaire Your Name: ____________________________, Your Mom: _____________________
Your Dad: _____________________
Mainly for Moms:
1. Tell us about your pregnancy;
Did you carry to full term? ________________________________________________
Describe any complications and when they occurred: ___________________________ _____________________________________________________________________ _____________________________________________________________________
2. Tell us about your delivery and birth of this child:
Did you use a midwife? Hospital? Obstetrician? _________ Did you have a C-Section? Were forceps used? ________
Were you induced? Vacuum Extraction?
Was it a difficult birth? Did you have an Epidural?
What was the baby=s APGAR Score? at 5 minutes? _____________
3. Tell us more:
Did you breastfeed? How long? What formula after?____________
Did you consume alcohol during your pregnancy? How much? _____________
How long? Did you smoke? How much? _
Did you take any medication during your pregnancy?
For what? What type?
________
_______
___________________
Any exposures to ultrasound? , How many?__________________________
__________
4. As a baby/toddler, (birth to 4 years), did any of the following occur?
___ Fall from a change table ___ Frequent crying spells ___ Tumble down stairs ___ Frequent fevers ___ Fall out of crib ___ Frequent bouts of diarrhea ___ Involved in car accident ___ Constipation ___ Fall off playground equipment ___ Sleeping problems ___ Play in AJolly Jumper@ ___ Frequent colds ___ Frequent ear infections ___ Colic ___ Tonsilitis ___ Did not gain weight ___ Reaction to vaccination ___ Other__________________
Please explain the above: ____________________________________________ ________________________________________________________________ ________________________________________________________________
5. As a young child, (5-12 years), did any of the following occur?
___ Fall from a tree ___ Bed wetting ___ Fall of a bicycle ___ Hyperactivity/Autism ___ Fall of playground equipment ___ Learning difficulties ___ Sports accident ___ Asthma ___ Car accident ___ Allergies ___ Stomach pains ___ Leg/knee pains ___ Scoliosis ___ Other__________________
Please explain the above: ____________________________________________ ________________________________________________________________ ________________________________________________________________
6. Tell us about any vaccinations your child has had: _________________________________________________________________________ ___________________________________________________________
Any reactions to any of these? ________________________________________ ________________________________________________________________
Were you told that you had a choice in vaccinating your child? ___YES, ___NO Would you like information on the Aother side@ of this issue? ___YES ___NO
7. As a child or adolescent, has your child experienced any of the following:
___ Headaches ___ Numbness in arms/hands ___ Foot/ankle/knee pains ___ Dizziness ___ Arm/wrist pains ___ Tingling in arms/legs ___ Ringing in ears ___ Sleeping problems ___ Neck/back pains ___ Asthma ___ Allergies ___ Shoulder pains ___ Hyperactivity ___ Stomach problems ___ AGrowing Pains@ ___ Fatigue ___ Weight gain/loss ___ Other ________
Please explain any of the above: _______________________________________ _________________________________________________________________ _________________________________________________________________
8. Which of the problems you have checked off is the worst? __________________________________________________________________________
Is this problem: Constant __, Intermittent __, Occasional __, Cyclic ___
9. How long has it persisted? _______________________________________
10. When it is at its worst, how does it make your child feel? _____________
11. What have you done about it that has NOT worked? __________________________________________________________________
______________________________________________________________
12. What makes it worse? ___________________________________________
13. What effect does this problem have of your child=s body functions? ______________________________________________________________
______________________________________________________________
On his/her participation in daily activities? _________________________
14. Describe any hospital stays: ________________________________________________________________________________________________
15. Approximately how many times have antibiotics been prescribed and forwhat conditions? _______________________________________________________________________________________________________________
16. List any medications your child is currently taking: _____________________________________________________________________________
17. To summarize, what is your purpose for this appointment? ___________ __________________________________________________________
__________________________________________________________
18. Is there anything else you feel we should know? ____________________________________________________________________________________________________________________________________________________________________________________________________________
Signature of parent or guardian: __________________________________
Date: ___________________________________________________________
***
Please answer the following questions so we may better understand how to help you:1. On a scale of 1 to 10 (10 being the most important) how important is your health to you? ________
On the COREscoreTM chart to the right:2. Please put an ‘X’ to score where you think you are today.
3. Please circle where you would like to be (your goal).
4. How long do you think it might take to get to where youcircled? _______
5. What things might you need to change to help you reachyour goal?
a. ___________________________________________b. ___________________________________________c. ___________________________________________d. ___________________________________________
6. If we could make recommendations that would not onlyaddress your main concerns, but could also help youwith improving your overall health, would you like tohear them?_____ yes _____ no
95-100EXCELLENT ______
90-94VERY GOOD ______
80-89GOOD ______
70-79TRANSITION ______
60-69CHALLENGED ______0-59
VERY CHALLENGED ______
Choosing chiropractic care is an exciting step towards regaining or improving your health and wellness. Old injuries, emotional tension, work and family situations along with poor dietary choices
add to your daily stress load. This can cause muscles to overreact and joints within the spine to lock. However, our greatest concern is when those ongoing stressful habits affect the inner nerve
connections, leaving you at risk for deeper health problems. Unwinding harmful spinal stress while coaching you towards a strong and vibrant lifestyle is what we love to do!
Our uses a sophisticated scanning system to detect hidden stress patterns. This accurate, computer-based analysis rates your stress on a scale from 0-100 and is known as the COREscoreTM.
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