Health fr Life Chirpractic At Clverdale Mall Unit #143-250 The East Mall Etbicke, ON, M9B 3Y8 416-232-1822 416-232-0060 Child and Adlescent Health Questinnaire Name:_ Birth date: Address:_ Telephne: Medical Dctr:_ Parent/ Guardian s Name: Hw did yu hear abut us? Sectin 1 Yur pregnancy and child s delivery 1. Did yu carry full term? 2. Describe any cmplicatins and when they ccurred: 3. Caesarean-Sectin? _ Were frceps used? _ Was it a difficult delivery? Was the delivery induced? Vacuum extractin? _ Did yu have an epidural? 4. Did yu cnsume any alchl during yur pregnancy? _ Hw much? _ Did yu smke during yur pregnancy? Hw much? _ Did yu take any medicatin during yur pregnancy? _ If yes, what type f medicatin? Hw much? _
Sectin 2 Yur child s daily activities 5. As a baby/ tddler (birth t fur years), did any f the fllwing ccur? Frequent crying spells Frequent fevers Clic Frequent ear infectins Sleeping prblems Antibitic use Frequent buts f diarrhea Use f a jlly jumper Any falls Tnsillitis 6. Please list any childhd illness: 7. As a child (5 years t present), have any f the fllwing ccurred? Asthma Bed wetting Allergies f Hay fever Stmach prblems Hyperactivity Dizziness Fatigue Any surgery _ Ringing in the ears Headaches Lw back pain Invlved in car accident Sprts accident Any perids f hspitalizatin Grwing Pains Neck Pain Numbness r tingling Sleeping difficulties Which f theses prblems are the wrst? Hw lng has this prblem persisted? 8. List any medicatins that the child is currently taking: _
9. Is there anything else that yu feel we shuld knw abut? _ 10. What d yu hpe t gain frm this appintment? Examinatin Fees Cnsultatin Cst ----------Cmplimentary--------- Examinatin $50.00 X-rays (if applicable) $90.00 I, the undersigned, as parent/ guardian, request and cnsent t the perfrmance f a chirpractic examinatin, adjustment and ther chirpractic prcedures including diagnstic x-rays, if necessary, n by the dctr and/ r anyne wrking in this clinic authrized by the dctr. I assume respnsibility fr the care and fees fr the abve mentined patient fr the duratin f their care. _ Print Child s Name Signature f Parent / Guardian Date Signed CONSENT TO CHIROPRACTIC TREATMENT
It is imprtant fr yu t cnsider the benefits, risks and alternatives t the treatment ptins ffered by yur chirpractr and t make an infrmed decisin abut prceeding with treatment. Chirpractic treatment includes adjustment, manipulatin and mbilizatin f the spine and ther jints f the bdy, sft tissue techniques such as massage, and ther frms f therapy including, but nt limited t, electrical r light therapy and exercise. Benefits Chirpractic treatment has been demnstrated t be effective fr cmplaints f the neck, back, and ther areas f the bdy caused by nerves, muscles, jints and related issues. Treatment by yur chirpractr can relieve pain, including headache, altered sensatin, muscle stiffness and spasm. It can als increase mbility, imprve functin, and reduce r eliminate the need fr drugs r surgery. Risks The risks assciated with chirpractic treatment vary accrding t each patient s cnditin as well as the lcatin and type f treatment. The risks include: Temprary wrsening f symptms- Usually, any increase in pre-existing symptms f pain r stiffness will last nly a few hurs t a few days. Skin irritatin r burn - Skin irritatin r a burn may ccur in assciatin with the use f sme types f electrical r light therapy. Skin irritatin shuld reslve quickly. A burn may leave a permanent scar. Rib fracture- While a rib fracture is painful and can limit yur activity fr a perid f time, it will generally heal n its wn ver a perid f several weeks withut further treatment r surgical interventin. Injury r aggravatin f a disc- Over the curse f a lifetime, spinal discs may degenerate r becme damaged. A disc can degenerate with aging, while disc damage can ccur with cmmn daily activities such as bending r lifting. Patients wh already have a degenerated r damaged disc may r may nt have symptms. They may nt knw they have a prblem with a disc. They als may nt knw their disc cnditin is wrsening because they nly experience back r neck prblems nce in a while. Chirpractic treatment shuld nt damage a disc that is nt already degenerated r damaged, but if there is a pre-existing disc cnditin, chirpractic treatment, like many cmmn daily activities, may aggravate the disc cnditin. The cnsequences f disc injury r aggravating a pre-existing disc cnditin will vary with each patient. In the mst severe cases, patient symptms may include impaired back r neck mbility, radiating pain and numbness int the legs r arms, impaired bwel r bladder functin, r impaired leg r arm functin. Surgery may be needed. Strke- Bld flws t the brain thrugh tw sets f arteries passing thrugh the neck. These arteries may becme weakened and damaged, either ver time thrugh aging r disease, r as a result f injury. A bld clt may frm in a damaged artery. All r part f the clt may break ff and travel up the artery t the brain where it can interrupt bld flw and cause a strke. Many cmmn activities f daily living invlving rdinary neck mvements have been assciated with strke resulting frm damage t an artery in the neck, r a clt that already existed in the artery breaking ff and travelling up t the brain. Chirpractic treatment has als been assciated with stke. Hwever, that assciatin ccurs very infrequently, and may be explained because an artery was already damaged and the patient was prgressing tward a strke when the patient cnsulted the chirpractr. Present, medical
and scientific evidence des nt establish that chirpractic treatment causes either damage t an artery r strke. The cnsequences f a strke can be very serius, including significant impairment f visin, speech, balance and brain functin, as well as paralysis r death. Alternatives Alternatives t chirpractic treatment may include cnsulting ther health prfessinals. Yur chirpractr may als prescribe rest withut treatment, r exercise with r withut treatment. Questins r Cncerns Yu are encuraged t ask questins at any time regarding yur assessment and treatment. Bring any cncerns yu have t the chirpractr s attentin. If yu are nt cmfrtable, yu may stp treatment at any time. Please be invlved in and respnsible fr yur care. Infrm yur chirpractr immediately f any change in yur cnditin. DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR I hereby acknwledge that I have discussed with the chirpractr the assessment f my cnditin and the treatment plan. I understand the nature f the treatment t be prvided t me. I have cnsidered the benefits and risks f treatment, as well as the alternatives t treatment. I hereby cnsent t chirpractic treatment as prpsed t me. Name (Please Print) Signature f patient ( r legal guardian) Date: _ 20 Signature f Chirpractr Date: _ 20