Please enable JavaScript in your browser to complete this form.Patient's Name: *FirstLastDate of Birth: *Sex:BoyGirlParent 1's Name:FirstLastParent 1's Email:Parent 1's Phone:Parent 1's Occupation:Parent 2's Name:FirstLastParent 2's Email:Parent 2's Phone:Parent 2's Occupation:Home Phone:Home Address:Who may we thank for referring you to us?In case of emergency, contact:Emergency phone number:How can we help your child?Wellness CheckupOtherIf "Other", please describe:If your child is already experiencing a symptom, please describe it:Has your child been treated on an emergency basis?NoYesPlease describe:Did you experience any complications during your pregnancy?Back/Other PainGestational DiabetesPre/EclampsiaPre-TermStrep BFatigueSwellingNausea/VomitingAny other complications? Please describe:Type of birth (check all that apply):EpiduralNormal/VaginalScheduled/InducedCaesareanBreechHomeHospitalBirth CentreAny problems during labour/delivery?JaundiceMeconiumAntibioticsRespiratory DistressCongenital AnomaliesExtended HospitalizationFailure to ThriveAny other problems during labour/delivery? Please describe:Infant FeedingBreastExpressedFormulaNumber of hours of sleep each night:Quality of sleep: Selected Value: 5 0 = Extremely Bad / 10 = Extremely GoodAt what age did the child respond to sound?At what age did the child hold head up?At what age did the child sit unsupported?At what age did the child crawl?At what age did the child stand?At what age did the child walk unsupported?Has your child had (check all that apply):Chicken PoxMeaslesMumpsRubellaRubeolaPertussis/Whooping CoughHas your child ever suffered from (check all that apply):AllergiesAnaemiaAsthmaArm ProblemsBack AchesBed WettingBroken BonesBehavioural ProblemsChronic Ear AchesColds/FluColicConvulsions/SeizuresDelayed SpeechDiabetesDizzinessDigestive IssuesFaintingHeadachesHeart TroubleHyperactivityHypertensionJoint ProblemsJuvenile ArthritisLeg ProblemsNeck ProblemsNeuritisOrthopaedic ProblemsParalysisPoor AppetiteRuptures/HerniasSinus TroubleTuberculosisWalking ProblemsHave you vaccinated your child?YesNoAs ScheduledDelayed ScheduleHave you or have you had any other conditions that you would like to inform us of?ALLERGIES (list):MEDICATIONS (list):SURGERIES (list):FAMILY HISTORY (list):How many children do you have?Children's ages:Other children's health concerns:For mothers - number of pregnancies:Are you currently pregnant?YesNoNot SureIf yes, what is your due date?Any health concerns regarding this pregnancy?GDPR Agreement *I consent to having Clane Chiropractic store this info. *Submit
