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KIDS HEALTH QUESTIONNAIRE

Parents or Guardians need to submit the Kids Health Questionnaire below for anybody under 18. Please submit the below form 24 hours prior to their appointment.

Birthday
Is there someone I can thank for referring you?
Has your child had their spine looked at before?

If yes, for what condition?

Has your child ever suffered any injury or serious illness?

If yes, please specify


Please write in your own words your child's main complaint.

At child's birth

Was it chemically induced?
Was a C-Section performed?
Were forceps used?

The child's symptoms in the past 6 months.

Please check any of the following symptoms your child has experienced in the past 6 months:

Was/Is your child breast or formula fed?

The child's current condition

Is your child accident prone?
Has the child had any falls down steps?
Has your child ever fallen from heights over 2 feet?
Has our child ever been involved in a motor vehicle accident?
Has your child ever been hospitalized or had surgery?
Is your child on medication?
Has your child had a spinal curvature (scoliosis) examination by an approved scoliosis determination procedures clinic?
Does your child have a learning disorder?
Does your child have poor posture?
Does your child show any sings of nervousness, twitching or excessive talking to themselves?

If you could improve one aspect of your child's health or behavior, what would it be?

Consent to Treatment

By e-signing this form, I agree and consent to the healing work.

I understand that with any healing process and work on the body, the symptoms may worsen before they get better.


I understand this care is designed to assist the body with healing by helping to remove stressors from the body. I understand that healing takes time and there is no quick immediate fix to the problem, and health is a process.


I have freely decided to undergo the recommended treatment and here by give my full consent to treatment.

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