Funnell Family Chiropractic Child Entrance Form (Age 2 - 12)
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2Funnell Family Chiropractic Child Entrance Form (Age 2 – 12)
Dear New Patient,
It is a pleasure to welcome you to our family of happy and healthy chiropractic patients. Please let us know if there is
any way we can make you and your family feel more comfortable. To help us serve you better, please complete the
following information. We look forward to working with you to build better health for your family.
Patient name: _______________________________________________________ Today’s date____________________________
Date of birth: ___________________________ Age: ________________
Sex: Male / Female (Please circle)
Address: __________________________________________________________________________________________________
Postal address if different: ____________________________________________________________________________________
Phone: Home: _________________________ Business (Please include contact name):___________________________________
Mobile: __________________________ Email address: ____________________________________________________________
Names of Parents/Guardians: ________________________________________________________________________________
School attended: ___________________________________________________________________________________________
Name of person who referred you (e.g. Midwife, friend…)? __________________________________________________________
Previous Chiropractor: _________________________________ Date of last visit: _______________________________________
Name of Medical Doctor: _____________________________________________________________________________________
Birth History:
Forceps
Vacuum extraction (Ventouse) Normal vaginal
Breech
Caesarian section:
Emergency / Planned? (Please circle which)
Complications during delivery?
Yes
No
Please list: __________________________________________________
Genetic disorders or disabilities:
Yes
No
Please list: __________________________________________________
Birth weight: ___________________________
APGAR Scores: ______________________________________________
Health History:
Check any of the following conditions your child has experienced:
Ear infections
Scoliosis
Seizures
Chronic Colds
Headaches
Asthma/Allergies
Digestive Problems
ADHD
Constipation
Growing/Back Pains
Colic
Bed Wetting
Car Accident
Temper Tantrums
Other ____________________
__________________________________________________________________________________________________________
Number of courses of antibiotics your child has taken: In the last six months: ______, Total during lifetime: _________
Please list other prescription medications taken: ___________________________________________________________________
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