Welcome to Oaktree. We look forward to meeting you!

Oaktree Infant Chiropractic Forms (0-24 Months)

Patient Information

Patient Name*
What is your preferred method of communication?
I consent to receiving email communication from Oaktree *
(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*
How did you hear about Oaktree Health?

Chiropractic History

Have you been to a Chiropractor before?*
Approximate date of last visit:

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. 


Were there any complications during pregnancy?*
Were there any ultrasounds during pregnancy?*
Were any medications taken during pregnancy?*
Were any vaccines administered during pregnancy?*
What health concerns (if any) were experienced during pregnancy?
Was the pregnancy a result of IVF? *
Were cigarettes/alcohol used during the pregnancy?*
Were miscarriages experienced prior to the pregnancy?*


Location of birth
Type of birth
Medications during labour:
Birth procedure/interventions:
Complications during delivery:
Genetic disorders or disabilities*
Did anything else happen after the birth?

Infant History

Was your baby breast-fed?
If breast-feeding, have there been any challenges?
Are you concerned with baby's head/skill development or shape?
Are you dealing with any of the following issues?

Chemical Stressors

Does your child have any food intolerances?*
Has your child had any vaccines?*
Has your child ever had antibiotics?*

Traumatic Stressors

Has your child ever been hospitalized post birth? *
Has your child ever had surgery?*
Has your child ever been involved in a car accident?*

Primary Health Concern

What is the purpose of today's visit?*
Is the problem:*

Secondary Health Concern (if applicable)

Is the problem:


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