Childhood Initial Consult Form (Neuro) Kids Initial Consult FormChild’s First NameLast NameDOB (dd/mm/yy)AddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweFamily InformationMother’s First NameLast NameMother’s contact number: Father’s First NameLast NameFather’s Contact Number: Parental Marital Status: Married Divorced/Separated Widow Single DefactoPlease list other children/residents in your home and their age: Parental ConcernsDoes your child have a formal diagnosis?Please list any medication/ supplements your child is currently onWhat are your child’s strengths? What areas of your child’s development are you most concerned with? How long has this been going for? What makes it better? What makes it worse? GoalsPlease list 4 goals that you would like your child to be working towards at Brain + Body Health. School InformationSchool name:YearChild’s teacher: School ProgressDoes your child have any major issues at school? If yes, please describe: Does your child have difficulties with: Reading Handwriting Spelling Creative writing Following directions Mathematics Memory Finishing tasks Organising Paying attention Restlessness OtherWhat are your child’s favourite subjects at school? What are your child’s least favourite subjects at school? Developmental HistoryWas your child: Breastfed Bottle-fedIf so, until what age?Did your child have any issues attaching/breastfeeding? Yes NoDoes your child have any difficulties eating certain types/textures of food? Yes NoIf yes, please describe. At what age did your child start crawling?At what age did your child start walking?Medical HistoryHas your child had frequent/any problems with the following? Diarrhoea Constipation Vomiting Allergies Seizures Recurrent ear infections Tubes inserted Parasites Mould Infection Food IntolerancesChildhood HistoryHas your child ever: Had an illness or condition? Had any allergies or sensitivities? Been in any car/sports/other accidents? Been hospitalised/had any surgeries? Participate in exercise/extra-curricular activities? Loss or change in sleep pattern? If you ticked any of the above, please specify: Other SymptomsHas your child ever experienced the following: Headache or fatigue? Rashes, birthmarks, bruises, masses or swelling? Colds, stuffed noses, soring, enlarged lymph nodes? Hearing difficulties/dizziness? Vision/eye alignment problems? Cough, asthma, loud breathing, shortness of breath? Constipation, diarrhea, black/bloody stools? Colic, burping gas, reflux, bloating, burning? Abdominal pain, vomiting, frequent nausea? Excessive thirst, poor/excessive appetite? Back/neck/joint pain or swelling? Walking, balance or coordination issues? Poor circulation, hot/cold hands or feet, palpitations?If you ticked any of the above, please specify: PlayDoes your child have friends? Yes NoHow often in a week does your child have an opportunity to play with friends?What are your child’s favourite activities/play things?Games/activities your child performs well:Games/activities your child avoids/has difficulties with:Does your child participate in extra-curricular activities? Yes NoIf yes, please list: Please read this consent form, discuss it with your practitioner if you would like to, and then provide consent where indicated. Patient Information: Chiropractic and other techniques used at this clinic are well recognised as being extremely safe health care interventions for people of all ages. However, as with all health care disciplines there is a risk of complications. This may include soreness, muscle, bone or joint injury, worsening of symptoms, vision, hearing or balance problems, stroke (estimated at less than 1 per million), or side-effects caused by the use of nutritional or herbal products that may be recommended. If I have any concerns, I will discuss them prior to treatment or during the course of a treatment program if any new concerns arise. Chiropractic adjustments (manipulation) of the spine are internationally recognized as being far safer in dealing with neck and low back pain than medication and many other alternatives. (A risk assessment of Cervical Manipulation JMPT, 1995. Manga Report, Ontario Ministry of Health 1993). I understand the abovementioned risk of treatment exist. However, I do not expect the practitioner to be able to anticipate all potential risk and complications associated with the proposed care. I hereby acknowledge my consent to undergo assessments and treatment at this clinic and understand that I may withdraw my consent at anytime. I consent to Chiropractic care I do not consent to Chiropractic careLaser therapy is a safe and effective relief of pain and reduction of symptoms associated with mild arthritis and muscle pain. Laser also promotes relaxation of muscle spasm and promotes vasodilation. K-Laser device have TGA approval in Australia. FDA cleared in the USA and CE in Europe. Pain relief from laser therapy may be dramatic and substantial, lasting for hours, days or weeks. However, your results may be minimal or insignificant. Adverse effects from laser therapy are normally rare and temporary. They may occur from multiple causes including hypersensitivity, pre-existing health conditions, thermal effects such as burns, excessive pressure from the probe, and laser over-stimulation. Laser light can damage the retina in your eye. Always wear the laser protective glasses provided. The most common adverse effects are: a) Temporary increase in pain the following day after receiving laser therapy b) Mild bruising from vasodilation or direct pressure of the handpiece c) Temporary dizziness d) Skin reaction from photosensitising drugs (erythema/burn). I consent to Laser therapy I do not consent to Laser therapyTENS is a treatment that administers mild electrical currents to the skin to relieve pain. A small, lightweight, hand-held, battery-operated device produces the electrical currents and lead wires send these currents to self-adhesive electrode pads that attach to your skin. While using a TENS machine, you will experience a non-painful tingling or buzzing sensation, and this can help to block or supress pain messages. Although TENS treatment is safe for most people, it is recommended that the following people avoid treatment: a) Pregnant women should avoid using TENS in the abdominal and pelvic regions b) People with epilepsy should avoid applying electrodes to the head or neck as it may induce seizures c) People with heart problems d) People with a pacemaker or another type of electrical or metal implant I consent to TENS therapy I do not consent to TENS therapyOur training, while extensive, does not qualify us to comment on or provide input on any medication you or your child have been prescribed. We ask that you continue to take any and all medication that you or your child have been prescribed by your specialist and that all questions regarding medication are directed to your prescribing Doctor I understand the aboveSubmit Form
