Child Form - To Be completed by a parent.

Our mission is to help restore and maintain function and balance in the bodies, minds, and lives of people of all ages, from infants to seniors. Our ultimate purpose is to help people live an optimally healthy life and reconnect with the joy of living. Our intention is to create a safe and compassionate environment for you to heal and become whole again. Thank you for your visit.

Please be prepared to fill out the entire form at one time.

The form will time out during inactivity. If you've been away from the page, please refresh it prior to beginning. 

Child's Information

Gender of Child

Parent's Information

Emergency Contact

Your Child's Health History

How can we help your child?
Has your child been treated on an emergency basis?

Pregnancy  History

Did you experience any complications during your pregnancy? (check all that apply)

Birth History

Type of birth (check all that apply):
(check all that apply):

Growth & Development

Infant feeding:

At what age did the child:

Has your child ever suffered from (check all that apply)?:
Have you vaccinated your child?

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY

SIBLINGS

Are you currently pregnant?

Client Consent

Please Initial Each Section: 

Client Consent

*The signature of a parent or guardian is required for clients under the age of 18.