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Please fill in the form
New Patient Questionnaire - Baby
Your baby's details
First Name
Last Name
Date of birth
Parent/Guardian Name(s)
Your Address
Address Line 1
Address Line 2
City
State
Postcode
Email
Phone Number
Who referred you to this clinic?
- Select -
Lactation consultant
Maternal Child Health Nurse
GP
Friend
Google
Website
Facebook group
Other
Please give more detail on your selection
Maternal Child Health Nurse Details
First Name
Last Name
Address
Address Line 1
Address Line 2
City
State
Postcode
Permission to send report?
Permission to send report?
GP Details
First Name
Last Name
Address
Address Line 1
Address Line 2
City
State
Postcode
Permission to send report?
Permission to send report?
Paediatrician details
First Name
Last Name
Address
Address Line 1
Address Line 2
City
State
Postcode
Permission to send report?
Permission to send report?
Reasons for attending Chirochild
Checkbox Field
Health concerns?
Chiropractic check up for optimal function?
Please list any specific health concerns for your child:
Your pregnancy
Did you have any of the following?
Blood pressure problems
Infection
Low iron
Low vitamin D
Stress
Medication/drugs used
Positional issues (breach/transverse)
Chiropractic care
Multiple ultrasounds
Excessive tiredness
Gestational age
What type of birth did you have?
Vaginal
Caesarian
Vaginal birth
Was the labour induced?
Yes
No
What was the presentation?
Anterior
Posterior
Breach
Pain medication?
Gas
Pethidene
Epidural
Assisted birth?
Forceps
Suction
How long was the labour in total?
How long was the second stage of labour?
Caesarian birth
What was the reason for the caesarean?
Were there any complications?
The newborn stage
At birth:
Weight
Length
Head circumference
Apgar score: 1 min
Apgar score: 5 mins
Did your baby receive antibiotics after the birth?
Yes
No
Feeding your baby
Do you breast feed?
Yes
No
Any difficulty with attachment to breast or fussiness?
Yes
No
Any difficulty with suck or swallow ability?
Yes
No
Did you experience any of the following?
Mastitis
Nipple damage
Tongue tie
Are there any foods or food groups you exclude?
On a typical day, what you most often eat for
Breakfast
Morning Tea
Lunch
Afternoon tea
Dinner
Dessert
Other snacks you regularly have which you have not mentioned
Water volume/day
Do you eat chocolate regularly?
Number of coffees/day
Number and type of cups of tea/day?
Supplements - now or since breastfeeding?
Medicines - now or since breastfeeding?
Which formula did you use?
Any issues with suck ability?
Any issues with swallow ability? (cough, gag, choking)
Your Baby's sleep
Night Time
How well does your baby settle to sleep:
Easily
With a little difficulty
Very difficulty
Extremely difficultly
On average how long does your baby sleep for?
0-1 hours
1-2 hours
2-3 hours
3-4 hours
Daytime
How well does your baby settle to sleep:
Easily
With a little difficulty
Very difficulty
Extremely difficultly
On average how long does your baby sleep for?
0-1 hours
1-2 hours
2-3 hours
3-4 hours
Please rate your baby's comfort
Nappy changes
Likes
OK
Dislikes
Hates
Tummy changes
Likes
OK
Dislikes
Hates
Getting in/out of car seat/capsule
Likes
OK
Dislikes
Hates
Being dressed
Likes
OK
Dislikes
Hates
Being bathed
Likes
OK
Dislikes
Hates
Your baby's body systems
The eyes and ears
Any gunky eyes or eye discharge?
Concerns with vision?
Concerns with eye movement?
Responds to your smile?
Responds to sounds?
Concerns with hearing?
The throat and chest
Snuffly/congested breathing?
Rattles, wheezes, vibrations in the chest?
Difficulty breathing or fast breathing?
Episodes of not breathing (apnea)?
Any blue lips/tongue?
Colour changes in arms/legs?
Detected heart defects?
The bowel and bladder
Any blood or mucus in the stools?
Straining with bowel motions? (grunting, tenses body)
Smelly urine?
rashes, spots, birth marks, lumps, moles?
Please rate your baby's ability to do the following:
Tummy time head use
Poor
Okay
Good
Not doing yet
Tummy time arm use
Poor
Okay
Good
Not doing yet
Head control
Poor
Okay
Good
Not doing yet
Muscle tone
Poor
Okay
Good
Not doing yet
Rolling front to back
Poor
Okay
Good
Not doing yet
Rolling back to front
Poor
Okay
Good
Not doing yet
Arm use
Poor
Okay
Good
Not doing yet
Commando crawling
Poor
Okay
Good
Not doing yet
All four crawling
Poor
Okay
Good
Not doing yet
Sitting
Poor
Okay
Good
Not doing yet
Pulling to a stand
Poor
Okay
Good
Not doing yet
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