Child Health History Profile

Please Read and Complete at the best of your knowledge on behalf of your child.

We highly advice both parents to participate in completion of this profile and being present for the results of your child examination, Doctors Report.

WELCOME and THANK YOU for applying as a patient in Healthy Kids & Family Chiropractic Center!

We are specialized in very unique researched-based neurological, spinal and postural rehabilitation that helps our patients recover their optimal health by restoring their normal nervous system function; often where many other ways have failed.

Because of this, we may not accept you as a patient until we are absolutely certain we know what is causing your condition, after performing all the necessary tests to establish an optimal spinal reconstruction program for you, and are completely confident to provide you with the best possible recommendations in your situation.

Please know, that it is a paramount for your recovery to follow exact and complete doctors recommendations. Based upon our understanding that your health will become your TOP PRIORITY we would love to accept you under care at our center.

We are looking forward serving you and thank you again for applying as a patient in our clinic.

Please complete your Health History Profile as detailed as possible to help doctor reviewing your situation before your initial visit and understand how can we serve you the best.

Research is showing that most of the health challenges that occur later in life have their origins during the developmental years, some starting at birth. Please answer the following questions to the best of your ability.
If Pain is PresentIndicate intensity by sliding the marker

Please check ALL of the following child might have EVER had even if you don’t think they are related to the current problem:

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