New Chiropractic Patient - 0-13 years of age

Parent / Carer / Guardian Email *

Parent / Carer / Guardian Name *

First

Last

Would you like to receive our Thrive Health Monthly Newsletter, full of news, events, health tips and more? (you can unsubscribe at any time) *

Yes
No

Mobile Phone Number *

Address *

Child's Name *

First

Last

Preferred Name

Date of Birth *

Child's Age *

Child's Gender *

Number of Siblings? *

Private Health Fund? *

How Did You Hear About Thrive Health Co. *

Please specify who referred you so we can thank them?

Has your child ever visited a Chiropractor before? *

Yes
No
Unsure

Have you been referred to us for a specific reason? *

Yes
No
Unsure

If yes for a specific reason, please detail?

Do you feel that your child is developing and reaching their milestones in a similar time to their peers? *

Yes
No
Unsure

If answered no, please explain

Please tick if you have any concerns about the following: *

Any areas of concerns not listed above?

Is your child under the care of a health professional? *

Yes
No

If yes, Name of Health Professional?

Is your child currently on any medications, vitamins, minerals, herbs etc? *

Yes
No
Unsure

If answered yes. Please list all medications, vitamins and doses

Mother's Health *

On a scale of 1 (low) to 5 (high) what were the Mother's average stress levels during pregnancy (home & work) *

Was IVF used to conceive? *

Yes
No

Please add details of Mother's Health and Allergies?

Mother's Family History?

Father's Family History?

On a scale of 1 (none) to 5 (high) please indicate the Mother's level of exercise during pregnancy? *

Any accidents, falls or car accidents? *

Yes
No

Experience any back pain? Please explain. *

How long did the Mother sit per day (work & home) *

Morning Sickness? *

Yes
No

Cigarette use or exposure? *

Yes
No
Unsure

What number pregnancy was this child? *

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On a scale of 1 (low) to 5 (high) what was the Mother's level of exhaustion? *

Was there any blood pressure issues for the mother? *

Yes
No

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Child's position during labour? *

Was/were there any of the following interventions used? *

Foreceps
Vacuum
Forceful pulling
Unsure

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Was/were the following drugs used?

On a scale of 1 to 5 (very alert) rate your child's alertness after birth? *

Please describe your child's birth. Please list any other medical interventions or drugs used? *

Was your child born *

Vaginally
Emergency C-Section
Planned C-Section

What was your child's birth weight and length? *

What was your child's head circumference? *

Weeks gestation? *

Please check if your child experienced any of the following? *

If APGAR score was less than 8, please detail reasons?

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Did your child have any of the following? *

How many hours was the mother in active labour (pushing)? *

If your child was born via C-Section, was your child low in the pelvis and engaged beforehand (longer than 3 weeks)?

Yes
No
Unsure

If your child was born in a hospital, how long did they stay in?

Name of Hospital child was born in? (or mark for home-birth)

Name of OBGYN or Midwife?

Please check boxes that apply *

Child recovered well after birth
Child slept well after birth
Skin-to-Skin was achieved after birth
Mother needed medical support after labour
Child woke itself to feed
None of the above

In the first 14 days - what was the average sleep blocks? *

<1hr block
1-2hrs
2-3hrs
3+hr blocks

What was your child's muscle tone like? *

Please indicate a check for yes for the following: *

Your child arched their head or back
Your child held their head or back in a particular way
Had certain postural habits while sleeping or awake
Cries when changes posture
Diagnosed with clicky hips
None of the above

What was your child's first milk (0-6wks)? *

Breast Milk
Formula
Both

Did your child experience any of the following? *

Experienced colic, reflux or persistent crying
Vit K or a vaccine given at birth
Smokers in the immediate family who held and took care of the child
Experienced skin rashes, eczema or dermatitis
Had to have any medicines
Experienced constipation or lots of gas/wind
None of the above

Any further details to add about the first 2 months of life?

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Please check for yes for the following:

Mother experienced post-natal depression
Child had difficulty sleeping
Child engaged with eye contact
Child frequently bangs their head on furniture
Child has quick changes in temperament
Child prefers to play by themselves than with the others
None of the above

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When out and about what item(s) did you predominately use?

Pram
Sling
Baby Carrier
Arms

Please indicate a check for yes for any of the following:

Child likes tummy time
Does/did >20 mins/day of tummy time
Child reaches milestones at similar times to their peers
Child has fallen from a high chair, table, couch or bed. Or bumped head firmly
Child has been in a car accident or near miss
None of the above

What did your child predominately drink/eat from 2 months?

Breast Milk
Formula
Both

Please indicate a check for yes for any of the following:

Child experienced ear infections or tonsillitis
Fevers over 39+
Skin rashes, eczema or dermatitis
Colic, reflux, persistent crying, lots of gas or tummy distension
Persistent colds and flus (> 2/yr)
None of the above

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What age did they begin to use words? *

When did your child start to sit on their own? *

Did your child have difficulty crawling properly? *

When did your child begin to walk? *

Please list any other details you feel we should know?

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Please list any childhood illnesses?

Please list any medications/antibiotics that have been used, for what conditions and how frequently?

Any hospitalisations or hospital visits? Why?

Has your child received the standard vaccinations? *

Yes
No

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Please indicate a check for yes for any of the following:

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Please indicate a check for yes for any of the following:

Do you have any further concerns about your child's health, growth or development?

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Please indicate a check for yes for any of the following:

Doesn't like or can't sit still for short periods
Difficulty learning to ride a bike
Avoids activities with movement or balance
Hesitant of stairs
None of the above

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Please indicate a check for yes for any of the following:

Does your child have difficulty with any of the following?

Please discuss any learning concerns?

Thrive Health Co. Care Agreement and Policy *

By ticking this box I consent and understand the information outlined in this agreement and policy as outlined below. And that the information I have provided is true, accurate and to the best of my knowledge.

For your Chiropractor to determine the appropriate care for your child a thorough examination must be completed.
By signing this form you grant permission for the Chiropractor to:
* Gather all appropriate information about your child, his/her gestation, birth and health history
* Perform a full examination with chiropractic, orthopaedic and neurological tests to assess his/her current level of health
and function
* Provide a chiropractic care plan at the report visit including chiropractic adjustments and adjunctive care where
appropriate

The Health & Safety of Your Child Comes First
By signing below I understand and agree with the following statements:
* The information provided is accurate and all inclusive
* With any health care modality there may be some risks associated with care provided. I have been informed and I
understand what those risks may be.

* I have had the opportunity to discuss with my child’s Chiropractor the nature of the care recommended, the risks
associated with the recommended care and the likely outcome
* I understand that the likely outcome of the care is not guaranteed
* I do not expect my child’s Chiropractor to anticipate and explain all risks and complications but rely upon the
Chiropractor to exercise judgment during the course of the care based upon the facts known at the time
* I have read the above and been given the opportunity to ask questions about this document and the examination
process, procedures and following report in detail
* I will notify the Chiropractor of any major falls, illnesses or other instances where my child’s health has been
compromised at any point during care
* I acknowledge the Chiropractor will use specific chiropractic techniques suitable for my child’s age and body type to
ensure safe and gentle care is provided

Current Research About Chiropractic Care For Kids
As with any health care physical examination and/or care provided support there is a risk (however small) of a condition changing or an adverse outcome from the treatment. Latest research (2014/2015) analysis showed no serious adverse events have been reported to be associated to care provided by a chiropractor since 1992, and no deaths from paediatric chiropractic care has been reported in the literature. Research (2009) conducted by the International Chiropractic Pediatric Association demonstrated chiropractic care is very safe for kids.
The research of 5,438 chiropractic visits, 577 children, parents indicated;
* Only two children ( <1%) experienced minor discomfort after an adjustment, which readily resolved with continued
chiropractic care
* The research showed both parents and doctors indicated a high rate of improvement with respect to the children’s
presenting complaints.
* Parents also reported better sleeping patterns, improvements in behaviour and, improved immune system function while
under chiropractic care.
JMPT 2014; (Published Online October 29 2014:1-14) Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the
Literature. Todd et al. Explore (NY). 2009 Sep-Oct;5(5):290-5. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practicebased
research network. Alcantara J, Ohm J, Kunz D.
JMPT 2015 Nov-Dec;38(9):699-712 Adverse Events to Chiropractic and Other Manual Therapies for Infants and Children: A review of the Literature. Todd AJ,
Carroll MT, Robinson A, Mitchell EK.

OUR CANCELLATION POLICY

Thrive Health Co provides allocated appointment times to ensure the provision of essential and high quality care at all times. Therefore, for non-attendance, cancellations or change of appointment day without notice of at least 12 business hours, you will incur a cancellation fee of the 50% of our standard price. Any cancellations provided at least 12 business hours prior to your appointment time, will be at no charge.

If we receive advanced notice that you are unable to attend, other clients who may require an appointment with a therapist may be able to be seen in your time slot. Please be considerate of other people who may be requiring an appointment and are unable to get in with a therapist in a timely manner or at a time that suits them.

OUR PAYMENT POLICY
I accept financial responsibility for my consultations and treatment. Fees are due at the time of visit unless arranged, and agreed upon, in advance. Unauthorised late payments will attract administration fees, details of which are available on request.

Referrals Appreciated - as we are a family owned and operated practice – the majority of our patients come via the kind referrals from our current patients – just like you – this reduces our need to waste money on expensive advertising and concentrate on what we do best – helping as many people as possible. We thank you in advance for your kind referrals and support.

New Chiropractic Patient - 0-13 years of age