Stittsville Infant Chiropractic Forms

Oaktree Infant Chiropractic Forms (0-24 Months)

Patient Information

Patient Name*

First Name

Last Name

Patient Gender

Name of Parent(s)

Address*

Address Line 1

Address Line 2

City

Province

Postal Code

Email Address*

Cell Phone*

Home Phone

Work Phone

What is your preferred method of communication?

Call Email Text

Other:

I consent to receiving email communication from Oaktree *

Yes No

(Emails we will send you include news updates from Oaktree. We will not spam you and you can unsubscribe at anytime. You will still receive appointment reminders and other important notices via email)

Patient's Date of Birth*

Weight:

Height:

Medical Doctor Name:

Referral:*

How did you hear about Oaktree Health?

Chiropractic History

Have you been to a Chiropractor before?*

Yes No

Name of Chiropractor and City

Approximate date of last visit:

Duration and Frequency of Care:

Prenatal and Birth History

The time babies spend in the womb is far from idle. The brain is changing more rapidly during this time than at any other time in development. It is an active time for the fetus to grow and explore - and of course, connect to its mother. New evidence from in-utero fetal brain scans show, for the first time, that this connection directly affects brain development: A mother's physical and mental stress during pregnancy changes neural connectivity in the brain and the nervous system of her unborn child.

Pregnancy

Were there any complications during pregnancy?*

No Yes

If yes, please describe:

Were there any ultrasounds during pregnancy?*

No Yes

If yes, please describe:

Were any medications taken during pregnancy?*

No Yes

If yes, please describe:

Were any vaccines administered during pregnancy?*

No Yes

If yes, please describe:

Was the pregnancy a result of IVF? *

No Yes

Were cigarettes/alcohol used during the pregnancy?*

No Yes

Were miscarriages experienced prior to the pregnancy?*

No Yes

If yes, how many?

Birth

Location of birth

Home Birthing centre Hospital

Other:

Type of birth

Vaginal C-section

Medications during labour:

None Induction (i.e. Pitocin, oxytocin) Epidural

Other:

Birth procedure/interventions:

Forceps Vacuum extraction Induced

Other:

Genetic disorders or disabilities*

Yes None

If so, describe:

Birth weight:

APGAR score:

Did anything else happen after the birth?

Jaundice NICU Medications

Other:

Infant History

Was your baby breast-fed?

No Yes

If yes, for how long?:

If breast-feeding, have there been any challenges?

Prefers one side Gags or chokes frequently Have tongue/lip ties

If applicable, at what age was your baby introduced to formula and/or solid foods? (please include the type)

How many hours between feedings? (if age appropriate)

Are you concerned with baby's head/skill development or shape?

No Yes

Are you dealing with any of the following issues?

Fussiness/gas Bowel/bladder issues Backward arching of head and neck Colic/reflux

Other:

How many hours is baby sleeping? (between feedings or during the night if applicable)

How many poops does baby have a day?

How many hours per day is baby spending in an 'upright posture'? (i.e. in a car seat, bouncy seat, swing):

How much tummy time is baby getting on parents and alone?

If applicable, what type of baby carrier do you use? (some affect hip development)

Chemical Stressors

Does your child have any food intolerances?*

No Yes

If yes, please list:

Has your child had any vaccines?*

No Yes

If yes, please list:

Has your child ever had antibiotics?*

No Yes

If yes, please list:

Total number of antibiotic rounds to date:

Does your child take any medication(s)? Which and for what condition(s)?

Traumatic Stressors

Please list any falls your child has experienced (i.e. from a bed, change table, down stairs, off couch, etc):

Has your child ever been hospitalized post birth? *

No Yes

If so, please describe:

Has your child ever had surgery?*

No Yes

If so, please describe:

Has your child ever been involved in a car accident?*

No Yes

If so, please describe:

Primary Health Concern

What is the purpose of today's visit?*

Wellness Check Up Specific Concern (Fill below)

What is the primary health concern for your child?

How long has your child had this condition?

What other health care professionals have treated this condition? What else have you tried?

Is the problem:*

Getting better Getting Worse Staying the same

Please rate the problem on how you think it is affecting your child:

Please rate the problem on how you think it is affecting your family:

Secondary Health Concern (if applicable)

What is the secondary health concern of your child?

How long has your child had this condition?

What other health care professionals have treated this condition? What else have you tried?

Is the problem:

Getting better Getting Worse Staying the same

Please rate the problem on how you think it is affecting your child:

Please rate the problem on how you think it is affecting your family:

Please share any additional health problems, concerns, or information

Submission

I understand that the purpose of today's visit is to determine if I am a candidate for chiropractic care and that I am responsible for any fees agreed upon by myself and the attending doctor. All examination fees will be explained to me before any tests are performed (Patients may be requested to sign a presented hard copy of this document upon arrival)*

Date*