Patient Introduction – Child & Adolescent · #204, 1740 Gordon Drive ♦ Kelowna, BC ♦ V1Y 3H2 ♦ 250-868-4880 [email protected] Patient Introduction – Child

#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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www.MyCOREscore.com

Documents

Patient Introduction – Child & Adolescent · #204, 1740 Gordon Drive ♦ Kelowna, BC ♦ V1Y 3H2 ♦ 250-868-4880 [email protected] Patient Introduction – Child