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Please fill in the form New Patient Questionnaire - Child

New Patient Submission - Child

Child's personal details

First Name

Last Name

Date of birth

Your Address

Address Line 1

Address Line 2

City

State

Postcode

Email

Phone Number

Who referred you to this clinic?

Please give more detail on your selection

Reasons for attending Family Tree Health

Checkbox Field

Health concerns?

Chiropractic check up for optimal function?

Please list any specific health concerns for your child:

Your child's sleep

How well does your child settle to sleep at night?

How many times does your child wake at night?

Do you have any concerns with:

Please rate your child's ability:

Balance

Poor

Ok

Good

Excellent

Ability to sit still

Poor

Ok

Good

Excellent

Language

Poor

Ok

Good

Excellent

Posture when standing

Poor

Ok

Good

Excellent

Co-ordination

Poor

Ok

Good

Excellent

Fine motor skills

Poor

Ok

Good

Excellent

Social abilities

Poor

Ok

Good

Excellent

Does your child enjoy a special activity or sport?

Does your child suffer any of the following:

Convulsions/Sezures/Epilepsy

Back pain

Neck pain

Arm pain

Leg pain

Headaches

Your child's body systems

The eyes and ears

Any gunky eyes or eye discharge?

Any light sensitivity?

Concerns with vision or hearing?

Concerns with eye movement?

The throat and chest

Snuffly/congested breathing?

Difficulty swallowing?

Rattles, wheezes, vibrations in the chest?

Episodes of not breathing (apnea)?

Difficulty breathing or fast breathing?

Detected heart defects?

Any blue lips or tongue?

Colour changes in arms/legs?

The bowel and bladder

Abdominal pain?

Constipation?

Loose stools?

Diarrhoea?

Any blood or mucus in the stools?

Straining with bowel motions?

Bloating?

Soiling (if over 3 years)?

Any smelly urine?

Bed wetting (if over 5 years)?

Any rashes, spots, birth marks, lumps, moles?

Your child's immmune system

Number of antibiotics in whole life?

Number of antibiotics in last 12 months?

Has your child ever had ear infections?

Yes

No

Has your child ever had chest infections?

Yes

No

Your pregnancy

Did you have any of the following?

Blood pressure problems

Infection

Low iron/low vitamin D

Stress

Medication/drugs used

Positional issues (breech/transverse)

Chiropractic care

Multiple ultrasounds

Excessive tiredness

What type of birth did you have?

Vaginal

Caesarean

Vaginal birth

Was the labour induced?

Yes

No

What was the presentation?

Breach

Pain medication?

Gas

Pethidine

Epidural

Assisted birth?

Forceps

Suction

How long was the labour in total?

How long was the second (pushing) stage of labour?

Caesarean birth

What was the reason for the caesarean?

Were there any complications?

The newborn stage

Weight

Length

Head circumference

Apgar score: 1 min

Apgar score: 5 mins

Did your baby receive antibiotics after the birth?

Yes

No

In the first year of life

Did you breast feed?

Yes

No

How long did you breastfeed for?

Any difficulty with attachment to breast or fussiness?

Yes

No

Any difficulty with suck or swallow ability?

Yes

No

Food/drink intake when breastfeeding

Please enter a typical daily intake below (knowing it may vary hugely) when breastfeeding.

If you don't have one of the options, please leave blank.

Breakfast

Morning tea

Lunch

Afternoon tea

Dinner

Dessert

Water per day

Tea per day

Coffee per day

Chocolate (Type & amount)

Snacks not listed above

Supplements

Medicines

Which formula did you use?

Maternal stress (out of 10)

Partner stress (out of 10)

Are you, as parents, well supported?

Any issues with the following in the first year of life?

Reflux or vomiting

Colic

Unsettled behaviour

Poor sleep

Digestive problems

Frequent illness

Any discomfort with the following in the first year of life?

Nappy changes

Tummy time

Getting in/out of car seat

Being dressed near shoulder/neck

Being bathed

Your child's motor development

Age when crawled (all 4)

Age first 'furniture walked'

Age first walked

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About The Tree

The Clinic
Our Team
Our Chiropractors

Holistic Services

Psychologist
Osteopathy
Psychology Martine Lynch
Chiropractor For Families
Adult Chiropractor
Chiropractor For Children

Opening Times

Mon: 9am-6pm
Tues: 9am-6pm
Wed: 9am-6pm
Thur: 9am-6pm
Fri: 9am–5pm
Sat: 8am–12pm
Sun: Closed

Contact Us

86 St Helena Rd, Briar Hill VIC

03 9435 8788

info@familytreehealth.com.au

Website Designed by Harry Vann