Fresh Life Chiropractic
#20 525 Highlands Blvd West
Lethbridge, AB T1J 5G3
(403) 331-3301
freshlifechiro@gmail.com
Information
Child's Name
Address:
City:
Postal Code:
Phone (home)
Phone (cell)
Birth date:
Age:
AHC #
Sex:
Weight:
Height:
Referred by:
Name of Parents/ Guardians:
Purpose of visit?
Other doctors seen for this condition
Yes
No
Other health problems:
Ear infections
Bed wetting
Recurring fevers
Asthma/allergies
Seizures
Temper tantrums
Colic
ADHD
Headaches
Scoliosis
Car accident
Growing/ back pains
Digestive problems
Chronic colds
Other
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