Name:    Home Phone: Address: Cell Phone:   City, State, Zip: Birth Date: E-mail Address: Parent/ Guardian: Cell Phone: 1) Research shows that spinal problems often begin at birth. How old was you child when they received their first chiropractic check up?:     Never: 2) Difficult, long and/or doctor-assisted births can cause spinal misalignments. How old was your child when they received their first chiropractic check up? : Never: 3) How long was the actual labor and delivery time? : 4) Have you ever been told that your child has a spinal curvature, spinal arthritis, or inherited spinal problem?: Yes No     If yes, specify: 5) Poor posture leads to poor health and often indicates a spinal problem. How would you rate your child’s posture?      1=Poor, 10=Excellent: 1 2 3 4 5 6 7 8 9 10 6) Did your child have early health challenges such as colic or frequent ear infections? : Yes No 7) Does your child suffer from any of the following?: Allergies Sinus Problems Bed Wetting Difficulty Concentrating Attention Deficit Disorder 8) Does you child have other health problems that concern you?: 9) Do you miss work or sleep often due to your child’s illness?: Yes No 10) Prescription medications may cause various side effects, hide the severity of health problems and hinder the body’s ability to heal. What medications is your child currently taking? : 11) Falls, sports, impacts and auto accidents can cause serious spinal problems. Is this visit related to an auto accident or injury?:      Yes   No        Date Of Incident: 12) If the doctor feels that your child will benefit from chiropractic care are you willing to follow his/ her recommendations?: Yes No