Child Chiropractic Form – Orleans Chiropractic Child Form - Orleans This form will take approximately 20 minutes to complete. If you would like to save your form and continue at another time, you may do so via the link at the bottom of each page. An email will then be sent to you with a link to complete the form when you wish to continue. This form is secure and all information is confidential. Thank you. Step 1 of 6 - PERSONAL INFORMATION 0% Name of Child* First Last Name of Parent(s)* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Parent's Home PhoneParent's Cell PhoneParent's Work PhoneParent's Email* I consent to receiving email communication from Oaktree*Emails we will send you will include news updates from Oaktree. We will not spam you and you can unsubscribe at anytime. You will still receive appointment reminders and other important notices via email.YesNoGenderFemaleMaleWeight (lbs)HeightBirthday* Who referred you to Oaktree?Do you have extended health care benefits that contribute to chiropractic care?YesNoUnsureAmount of chiropractic benefits per year:CHIROPRACTIC HISTORYHas your child ever been to a chiropractor before?YesNoWere x-rays taken?YesNoUnsureName of ChiropractorCity City Date of last visit (approximate year/month)Duration & Frequency of CareFor how long did your child see your chiropractor and how many times per week? Save and Continue Later PREGNANCY HISTORYComplications during pregnancy?YesNoComments on the complications during pregnancy:Ultrasounds during pregnancy?YesNoHow many ultrasounds did you recieve?Medications during pregnancy?YesNoWhat other medications do you take during your pregnancy?Please list any medications you took. Add an extra line for each additional medications.Name of medicationUsed for what condition BIRTH HISTORYLocation of birth? Hospital Home Birthing center Other Please specify "other"Type of birth? Vaginal C-section Breech Resuscitation Comment on type of birth:Complications during delivery?YesNoComments on the complications during delivery:Medications during delivery?YesNoWhat other medications do you take during your delivery?Please list any medications your child has taken. Add an extra line for each additional medication.Name of medicationUsed for what condition Birth procedure / interventions?Check any/all that apply Forceps Vacuum extraction Induced Other Please specify "other"Any evidence of birth trauma?Check any/all that apply Fast or excessively long birth Odd-shaped head Bruises Stuck in birth canal Cord around neck Respiratory depression Other Please specify "other"Cigarette / alcohol use during pregnancy?YesNoComment on cigarette / alcohol use during pregnancy:Genetic disorders or disabilities?YesNoComment on genetic disorders or disabilities?Birth weight? Save and Continue Later FEEDING HISTORYWas the baby breastfed?YesNoHow Long did you breastfeed for?Please indicate how many days or months.If applicable, at what age was the baby introduced to formula?Please list at what age they were introduced and what type(s) / brand(s) were given.Age IntroducedType(s)/Brand(s) of Formula If applicable, at what age was the baby introduced to solid foods?Please list at what age they were introduced and what type(s) were given.Age IntroducedType(s) If applicable, at what age was the baby introduced to cow's milk?CHEMICAL STRESSORSDoes the child have any known food intolerances?Please list any food intolerances the child has. Add an extra line for additional intolerances/foods. Has the child receive any vaccinations?YesNoWhat vaccinations did they receive?Please list any vaccinations the child has received. Add an extra line for additional vaccinations. Has the child taken any antibiotics?YesNoWhat antibiotics have they taken?Please list any antibiotics the child has taken. Add an extra line for additional antibiotics. Total # of antibiotic rounds to date:Does the child take any medication(s)?Please list any medications your child takes. Add an extra line for each additional medications.Name of medicationUsed for what condition Save and Continue Later TRAUMATIC STRESSORSProvide as much information as possible and if applicable.Falls the child has experienced(ex. from a bed, changing table, down stairs, off couch ... ) Please list type of fall and approximate date. Add an extra line for each fall.Type of FallApproximate Date Has the child ever been hospitalized?YesNoComment on child's hospitalization:Has the child ever had surgery?YesNoWhat surgeries were performed on the child?Please list any surgeries your child has had, including the date and for what condition. Add an extra line for each individual surgery.Year PerformedFor what condition Has the child ever been involved in a car accident?YesNoComment on the car accident(s)Does the child play any high impact sports?YesNoWhat high impact sport(s) does the child play?Please list any high impact sports the child plays. Add an extra line for each sport. How often does the child participate in aerobic exercises? (at least 30 minutes per day)0 days/week1-2 days/week3-4 days/week5-7 days/week Save and Continue Later PURPOSE OF VISITWhat is the purpose of your visit? Check-up Prevention Specific Concern PRIMARY HEALTH CONCERNSWhat is your present primary health concern for the child?How long has the child had this condition?Please specify in terms of weeks, months, or years.What aggravates this condition?Please list anything that aggravates the child's condition. Add an extra line if needed. What relieves this condition?Please list anything that helps relieve the child's condition. Add an extra line if needed. List other health care professionals who treated this condition:Please list any other health care professionals who have helped treat your child's condition. Add an extra line for additional professionals.NameSpecialty SECONDARY HEALTH CONCERNSDoes your child have a secondary health concern?YesNoWhat is the secondary health concern?How long has the child had this condition?Please specify in terms of weeks, months, or years.What aggravates this condition?Please list anything that aggravates the child's condition. Add an extra line if needed. What relieves this condition?Please list anything that helps relieve the child's condition. Add an extra line if needed. List other health care professionals who treated this condition:Please list any other health care professionals who have helped treat your child's condition. Add an extra line for additional professionals.NameSpecialty OTHER HEALTH PROBLEMS, CONCERNS OR ADDITIONAL INFORMATIONAddtional informationPlease outline any additional health problems, concerns or additional information. Save and Continue Later CONDITIONS & SYMPTOMSPlease check any of the following signs of organ malfunction or dis-ease your child is experiencing or has experienced in the last 6 months. Please select any/all the apply.Head / Neck Blurred / failing vision Deafness / ringing in ears Earaches Sore Throat / tonsillitis Thyroid problems Sinus problems Environmental allergies Cardiovascular system Chest pain Shortness of breath Swelling of legs Respiratory system Frequent bronchitis History of pneumonia Chronic cough Spitting up phlegm / blood Difficulty breathing Tuberculosis Pneumonia Asthma Digestive system Heartburn / indigestion Stomach cramps Constipation / diarrhea Crohn’s disease Ulcers Belching / gas Nausea or vomiting Liver / gall bladder problems Colon trouble Black / bloody stool Irritable bowel syndrome Musculoskeletal system Painful joints Painful muscles Tendinitis Headaches / migraine Neck pain / stiffness Tension across left shoulder Tension across right shoulder Numbness-tingling in left arm/hand Numbness-tingling in right arm/hand Numbness-tingling in left leg/foot Numbness-tingling in right leg/foot Mid-back pain / stiffness Lower-back pain / stiffness Scoliosis / spinal curvatures Faulty posture Painful tailbone Foot trouble Location of tendinitis General symptoms Fever / chills / sweats Frequent colds Fainting / dizziness Seizures / convulsions Skin problems Tremors Loss of balance Unexpected weight loss / gain Anemia HIV / AIDS Loss of sleep Poor memory / concentration Learning disability Irritable / nervous / tension Depression / emotional problems Anxiety Decreased energy / fatigue Tired / lethargic Autoimmune disease Antibiotic use Cancer Other Location/type of cancerPlease specify other condition(s)CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.