Infant & Child Health History Form
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Infant & Child Health History Form
Balance Chiropractic, 209 Bayfield Street, Barrie ON L4M 3B4 (705)252-2222
□ Dr. Amanda Ostrowski
□ Dr. Matthew Ostrowski,
, B.Kin., D.C.
B.Sc., D.C.
Child’s Name:
Sex: M F
Date (dd/mm/yyyy): ____/_____/_____
Age:
Birth date (dd/mm/yyyy): ____/_____/_____ Parent(s’) Name(s): _________________________________
Address:
City:
Postal Code:
Phone: (home)
(work)
(cell)
Email:
Medical doctor’s name and address:
Date of last appointment: _____________________
Previous chiropractor’s name and address:
Date of last appointment:
Who may we thank for referring you? / How did you hear about the office?
WHY THIS FORM IS IMPORTANT In this office our focus is on assisting people to function optimally in order for
them to become more self aware, stronger, healthier and for improved adaptation to everyday stresses. Completion of
this form provides us with an improved understanding of your child’s physical, emotional and chemical stresses that
can gradually overwhelm the body and contribute to health problems.
#1 Current Health Concern(s):
(If there are no current concerns and this assessment is to ensure optimum health and
functioning of your child, please skip to section #2.)
Please mark the area(s) on your body that are causing you pain or unusual sensation(s) with the appropriate symbols.
Numbness
NNNNN
NNNNN
NNNNN
Burning
XXXXX
XXXXX
XXXXX
XXXXX
Dull &
DDDDD
DDDDD
Aching
DDDDD
DDDDD
●●●●●●
Pins &
●●●●●●
Needles
●●●●●●
●●●●●●
R
L
L
R
SSSSSS
Sharp &
SSSSSS
Stabbing
SSSSSS
SSSSSS
Tight &
TTTTT
TTTTT
Stiff
TTTTT
TTTTT
FRONT
BACK
Location of major complaint:
When did it begin?
Rank the level of discomfort
Is it getting (circle): worse better constant
(1 = minimal to 10 = extreme):
/10
How often does it occur?
What relieves it?
Does it cause problems somewhere else?
What aggravates it?
Any associated or related concerns?
Other professionals seen for this?
(OVER)
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