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ForeverYoung Chiropractic Kingston Ontario

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Youth Intake Form

Thank you for choosing ForeverYoung!

If you have booked an initial exam with us, please take the time to fill out this form the best you can prior to your appointment day. This helps to keep the clinic running smoothly and your appointment on time!

Who may we thank for referring you?*

Parent's First Name:*

Parent's Last Name:*

Child's First Name*

Child's Last Name*

Biological Gender:*

Child's Date of Birth:*

Year

Month

Day

Current Address with City and Postal Code:*

Best Phone Number to Reach you at?*

Email*

Name of Spouse / Partner:

Name of Siblings and Ages:

Occupation:

Employer:

Band Member ID:

HealthCare Providers

Family Doctor:

Paediatrician:

Massage Therapist:

Naturopath:

Acupuncturist:

Other Care Provider:

Chiropractic History

Have they had previous chiropractic care?

If yes, have they been adjusted?

Conditions treated for in last year?

Reason for Visit

Are you currently seeking:

Reason for visit / main concern?*

When did their complaint start?

What may have caused the problem?

Is the complaint getting:

Duration of symptoms?

Is the complaint worse at certain times of day?

Has the complaint affected their:

Daily activities

Sleep

Appetite

School / Work

Sports / Hobbies

Family Life

Has this complaint happened before? If so, when?

What makes their complaint worse?

What makes their complaint better?

Accidents and Health History

Have they been in any MVA / ATV accidents? If so, when and any known trauma?

Any hospitalizations or surgeries?

If yes, for what and when?

Any sport / recreational traumas?

If yes, what and when?

Do they experience frequent illnesses/colds/flu/respiratory?

If yes, please explain.

Does your child poop everyday?

If no, how frequently does your child poop?

Does your child have any difficulties pooping? (straining, redness in the face)

If yes, please explain.

Any environmental allergies?

Postural Stress / Habits:

Sitting >6hrs

Standing >6hrs

Screen >6hrs

Repetitive Lifting >15lbs

Family History of:

Heart Disease

Diabetes

Arthritis

Cancer

Other

Child's Pregnancy and Birth History

How many weeks did you carry them?

Did you have any trauma / illness while pregnant?

If yes, what did you experience.

Did you consume alcohol while pregnant?

If yes, how much?

Did you smoke during pregnancy?

If yes, how much?

Any smokers in the home?

Any drugs or medications taken during pregnancy?

If yes, what?

Child was born at?

Hospital

Birth centre

Home

Other

Childs birth was?

Vaginal Without Intervention / medication

Interventions

C-section

If interventions, what applies?

Foley

Medication

Epidural

Episiotomy

Vacuum Extraction

Forceps

Manual Extraction

Other

If C-section performed, was it?

Emergency

Scheduled

Any known complications from the birth?

Birth Weight and Height?

Was infant alert and responsive within 12hrs of delivery?

Nutritional and Health Intake

Are you currently breastfeeding?

Any difficulties latching?

If yes, what do you notice?

Is your child a mouth breather?

Did your child have a tongue tie?

If yes, did they get the tie revised?

Was your child formula fed?

At what age was formula introduced?

At what age was your child introduced to cow's milk?

Started solids at what age?

Is your child vaccinated?

Any adverse reactions to vaccinations?

Any Antibiotics used?

If yes, please explain.

List any medications / supplements your child is currently taking.

Do you have any pets at home?

How much soda pop do they consume in a day?

How much water do they drink per day?

How often do they eat fast food in a week?

Any food allergies?

How would you rate their current nutrition?

Psychological Stressors

Any difficulty with bonding?

If yes, please explain:

Any behavioural concerns?

If yes, please explain:

Any night terrors, sleepwalking, or difficulty sleeping?

If yes, please explain:

How many hours of sleep does your child get per night?

What what age did your child sleep through the night (5 hours)?

Does your child attend Daycare / Childcare?

If yes, at what age did they start?

How many hours of TV / iPad / Phone / Computer does your child watch per day?

Is your child involved in any activities such as clubs or sports?

Are you concerned at all with your child's development this far?

If yes, please explain.

Quality of Life

Current level of negative stress?

What is creating most stress?

How well do they cope with stress?

Current energy levels?

How often do they currently exercise / activity at least 60min?

What type of exercise / activity do they participate in?

How much sleep do they get a night?

What is their ideal sleep position?

Stomach

Back

Side

All over

Goals

What do you expect from their chiropractic care?

What's your greatest motivation for care in our clinic?

Does your spouse / partner have any health concerns?

Do any of your children have any health concerns?

Is there anything else you would like us to know?

613-507-5007

510 Canatara Court

Kingston, ON K7M 0G3

ForeverYoung Chiropractic Shannonville Ontario

613-966-5855

Shannonville, ON K0K 3A0

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