Please download this form by clicking on the link below, then print it, sign it and bring it to your first session. Thank you!
About Your Child
Parent’s names __________________________________________________________________
City ___________________________ State _______________ Zip _________________________
Phone (home) __________________ (cell) _________________ (work) _____________________
Birthdate ______/______/______ Sex: M _____ F _____ Year in school __________________
Who may we thank for referring your child to the Café of Life, or, how did you hear about us?
Reasons for seeking service at the Café of Life: ________________________________________________
Has your child been to a Chiropractor before? _____________________________________
When? ________________________________ Dr. _______________________________________
What are your child’s hobbies or interests? ________________________________________
Subluxation, or nerve interference, is caused by physical, chemical, and emotional stress.
Please answer these questions as best as you are able:
Birth information: Length of labor ________________________________________________
Type of delivery: vaginal _______ cesarean ________ breech _________ forceps ________
vacuum extraction __________ home birth ________ any other difficulties? ___________
Is your child uncomfortable in certain positions (side, back, stomach, etc) _________ __________________________________________________________________________________
Has your child had any accidents, falls, or traumas? Please describe: ______________
Has your child had any surgeries? ______________________________________________
Has your child been diagnosed with any illness or disease? ________________________
What sports or activities does your child participate in? ____________________________
Does your child eat a balanced diet?
Circle his/her intake of: (Z=Zero, L=Low, M=Med, H=High)
Meat Fruits Vegetables Breads/Grains Dairy Products
Z L M H Z L M H Z L M H Z L M H Z L M H
Sugar (candy, snacks) Pop
Z L M H Z L M H
Was (is) your child breast fed? _________ For how long? ____________________________
Was your child vaccinated? _____________ Did he/she have a reaction? ___________
If so, please describe: ______________________________________________________________
Does your child take any medications or drugs? Which ones, and for how long?
Is your child allergic to anything? _________________________________________________
What is the level of stress in your child’s life in these areas? (low, medium, high)
Home _______ School _______ Parents _______ Friends _______ Family _________
Siblings _______ Health _________ Sports _________ Activities _________
Is there anything else we should know about your child? __________________________
Thank you for allowing us to serve your child!