Childhood Initial Consult Form (Neuro)

Kids Initial Consult Form

Child’s First Name

Last Name

DOB (dd/mm/yy)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Family Information

Mother’s First Name

Last Name

Mother’s contact number:

Father’s First Name

Last Name

Father’s Contact Number:

Parental Marital Status:

Married

Divorced/Separated

Widow

Single

Defacto

Please list other children/residents in your home and their age:

Parental Concerns

Does your child have a formal diagnosis?

What 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?

Goals

Please list 4 goals that you would like your child to be working towards at Brain + Body Health.

School Information

School name:

Year

Child’s teacher:

School Progress

Does 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

Other

What are your child’s favourite subjects at school?

What are your child’s least favourite subjects at school?

Developmental History

Was your child:

Breastfed

Bottle-fed

If so, until what age?

Did your child have any issues attaching/breastfeeding?

Yes

Does your child have any difficulties eating certain types/textures of food?

Yes

If yes, please describe.

At what age did your child start crawling?

At what age did your child start walking?

Medical History

Has your child had frequent/any problems with the following?

Diarrhoea

Constipation

Vomiting

Allergies

Seizures

Recurrent ear infections

Tubes inserted

Parasites

Mould Infection

Food Intolerances

Childhood History

Has 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 Symptoms

Has 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:

Play

Does your child have friends?

Yes

How 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

If 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 care

Laser 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 therapy

TENS 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 therapy

Childhood Initial Consult Form (Neuro)

Family Information

Parental Concerns

Goals

School Information

School Progress

Developmental History

Medical History

Childhood History

Other Symptoms

Play

Recent Posts

Recent Comments

Location

Contact

Opening Hours

Services

Conditions