Please fill in the form New Patient Questionnaire - Megan

Megan's Intake Form - Child

Dr Megan Azer

Chiropractor & Certified NET Practitioner

Child New Patient form

Welcome! Please fill in this form to the best of your ability.

Patient's details

First Name

Last Name

Date of birth

Age

Parent/Guardians names

Contact Number

Your Address

Address Line 1

Address Line 2

City

State

Postcode

Email Address

How did you hear about us?

Health Concerns

Has your child previously received chiropractic care? If so, what was the reason?

What concerns do you have regarding the health of your child?

Birth

The birth of your child can give vital clues as to potential health concerns.

Briefly describe the birth of your child

Do you believe that the birth was traumatic to your child?

Yes

Were there any complications?

Feeding, sleeping & crawling

Was/is your child breastfed? For how long?

Did/does your child have any feeding difficulties?

Yes

Did/does your child suffer from any colic?

Yes

Did/does your child suffer from any reflux?

Yes

In regards to sleeping, would you say your child is a:

Very poor sleeper

Poor sleeper

Average sleeper

Good sleeper

Very good sleeper

Has your child started crawling?

Has your child started walking?

Other complaints

Select any of the following symptoms your child has experienced in the last 6 months

Low back pain

Growing pains

Digestive trouble

Ear aches/ear infections

Poor sleeping habits

Constipation/diarrhoea

Learning difficulty

Hyperactivity

Neck pain

Asthma

Sinus pain

Breathing issues

Fatigue

Bed wetting

Chronic colds

Visual disorders

Headaches

Allergies

Scoliosis

Tonsilitis

Recurrent chest infections

Rashes/eczema

Poor coordination

Recurrent stomach aches

Trauma, illness and medical history

Is your child accident prone?

Yes

Has your child had any falls or trauma?

Has your child every had a bone fracture or dislocation?

Has your child ever been in a motor vehicle accident?

Has your child ever been hospitalised?

Did you choose to vaccinate your child?

Is your child on any medication?

Has your child received any other medications?

Nutrition and exercise

How healthy is your child's diet on a scale of 1 to 5?

What sports does your child participate in and how often?

How much time does your child spend time on the computer / video games / watching television?

Mental/emotional stress

Please tick the appropriate box. Does your child experience any of the following (even if mild)

Family stress

Stress at school

Loss of a loved one

Any other stress?

If you could improve one aspect of your child’s health or behaviour, what would it be?

Wellness Check

Please complete this online wellness check and email your results to hello@meganazer.com.au

https://www.wellnesscheckonline.com/check1.php

Thank you.

CONSENT TO CHIROPRACTIC CARE

PRIVACY POLICY STATEMENT
In accordance with the new Privacy Act, all information relative to your case is held in total confidence. However, your consent is necessary to allow us to exchange information between chiropractors within this clinic. Also when appropriate, relevant information regarding your case may be sent to other medical and healthcare practitioners for the proper and effective management of your condition.

Signature

Sign Here

Date

PATIENT INFORMATION
When performed by a qualified chiropractor, spinal manipulation is an effective and safe method of treatment for many painful conditions. There is however risks associated with any treatment, and I am required to inform you of these, even though there has never been a case in this clinic (other than post-treatment muscle and joint soreness).
Please Read the following carefully and write down any questions you may have.
I hereby request and consent to the performance of chiropractic treatment and/or NET on my child by Dr. Megan Azer and/or any other chiropractor working in this clinic.
I have had the opportunity to discuss with Dr. Azer the nature and purpose of Chiropractic treatment.
I understand that results are not guaranteed.
I understand, and I am informed that, as in the practice of medicine, in the practice of chiropractic there are some very slight risks to treatment, including, but not limited to, muscle and joint soreness, muscle strains, joint sprains, fractures, disc injuries, nerve injuries, stroke and stroke-like episodes.
I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgement during the course of the treatment, which the doctor feels at the time, based upon the facts then known, and is in my best interests.
I have read the above and I have also had the opportunity to ask questions about its content.
I intend this consent form to cover the entire course of treatment for my child’s present condition, and for any future condition(s) for which I seek treatment. I understand that I can withdraw my consent for my child at any time.

Parent/Guardian name

Date

Signature

Sign Here