Funnell Family Chiropractic Baby Entrance Form
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2Funnell Family Chiropractic Baby Entrance Form
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.
Baby’s name: __________________________________________________ Today’s date: _________________________
Date of birth: _____________________ Age: ______________________
Sex: Male / Female (Please circle)
Address: __________________________________________________________________________________________
Postal address if different from above: ___________________________________________________________________
Phone: Home: ___________________________ Business (Please include contact name):__________________________
Mobile: ______________________________
Email address: ______________________________________________
Names of Parents/Guardians: __________________________________________________________________________
Name of person who referred you (e.g. Midwife, friend’s name…):______________________________________________
Reason for visit to us today: ___________________________________________________________________________
__________________________________________________________________________________________________
Previous Chiropractor: _________________________________
Date of last visit: _______________________
Name of Plunket Nurse: ________________________________
Date of last visit: _______________________
Name of Medical Doctor: _______________________________
Date of last visit: _______________________
Pre-natal History:
Name of Midwife/Obstetrician: _________________________________________________________________________
Complications during pregnancy?
No
Yes List: ___________________________________________
Ultrasounds during pregnancy?
No
Yes Number: _______________________________________
Medications during pregnancy/delivery?
No
Yes List: ___________________________________________
Cigarette/Alcohol use during pregnancy?
No
Yes
Birth History:
Location of birth:
Hospital
Home
Forceps
Vacuum extraction (Ventouse)
Normal Vaginal
Breech
Induced
Caesarian section: Emergency / Planned
Complications during delivery?
No
Yes
List: _______________________________________________
Genetic disorders or disabilities?
No
Yes
List: _________________________________________
Birth weight: _________________________________
APGAR Scores: ______________________________________
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