Kids Health Questionnaire

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This field is for validation purposes and should be left unchanged.

Name*

First Last

Parents Name*

D.O.B.*

Address*

P/Code*

Phone (Home)*

Country Phone Number

Phone (Work)*

Country Phone Number

Phone (Mobile)*

Country Phone Number

Email Address*

Enter Email Confirm Email

How did you discover our office and the services we offer?*

Has your child had their spine looked at before?*

Yes

For what condition?*

Were X-Rays taken?*

Yes

Has your child ever suffered any injury or serious illness?*

Yes

Please specify*

Please write in your own words your child's main complaint*

At the Child's Birth:

Was it chemically induced?*

Yes

Was a C-Section performed?*

Yes

Were forceps used?*

Yes

The child's symptoms in the past 6 months

Please tick any of the following symptoms your child has experienced in the past 6 months.

Lower Back Pain

Digestive Troubles

Headaches

Sleeping Disorders

Ear / Throat Infections

Fatigue

Hyperactivity

Meningitis

Constipation

Rashes

Milk or Lactose Intolerance

Neck Pain

Asthma / Alergies

Loss of Hearing

Cold / Flu

Breathing Problems

Irritability

Blood Noses

Diarrhoea

Bed Wetting

Colic / Reflux

Sinus Problems

Was/ls Your Child Breast or Formula Fed?*

Breast Milk

Formula Feed

Formula Feed, What Brand?*

The child's current condition:

Is your child accident prone?*

Yes

Has the child had any falls down steps?*

Yes

Has your child ever fallen from heights over 2 feet?*

Yes

Has your child ever been involved in a motor vehicle accident?*

Yes

Has your child ever been hospitalised or had surgery?*

Yes

Has your child ever had any broken bones or sprain injuries?*

Yes

Is your child on medication?*

Yes

Has your child hada spinal curvature (scoliosis) examination by an approved*

Yes

Scoliosis determination procedures clinic?*

Yes

Does your child have a learning disorder?*

Yes

Does your child have poor posture?*

Yes

Is your child nervVous, or has anyone suggested that your child was nervous?*

Yes

Does your child show any signs of nervousness, twitching or excessive talking to themselves?*

Yes

If you could improve one aspect of your child's health or behaviour, what would it be?*

Signature of Guardian / Parent

Date*

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Therapeutic Services

For Institutions

Practical Information

Kids Health Questionnaire

At the Child's Birth:

The child's symptoms in the past 6 months

The child's current condition:

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Programs

Therapeutic Services

For Institutions

Practical Information

Kids Health Questionnaire

At the Child's Birth:

The child's symptoms in the past 6 months

The child's current condition:

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