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  • PRESENT HEALTH COMPLAINTS/CONCERNS:
  • OFTEN SEEMINGLY UNRELATED SYMPTOMS CAN MANIFEST AS OTHER HEALTH CONCERNS: (please check if your child has had or has any of the following):

  • HISTORY OF BIRTH
  • GROWTH & DEVELOPM ENT
  • At what age did the child:
     
  • FAMILY HEALTH HISTORY
  • Please note any health problems (ie. cancer, hereditary conditions, diabetes, heart disease, etc.) that are present in:
  • Since problems that chiropractors look for and detect can be related to many types of stressors, the following information is also very important to us. 

  • PHYSICAL STRESSORS
     
  • CHEMICAL STRESSORS
  • PSYCHOSOCIAL STRESSORS
  • Thank you for completing our Child Health History Questionnaire. If there are any other questions or concerns which you have, you may write them down in the space below.

  • Should be Empty: