Bruce Street Family Chiropractic
81 Bruce St.
Kitchener, ON N2B 1Y7
(519) 743-6339
erika@brucestreetfamilychiropractic.com
SYMPTOMS AND ILL HEALTH (PRESENT STATE OF ILL HEALTH)
Years of uncorrected injury or damage show up as acute or chronic symptoms or health problems.
Main purpose for this appointment:
Have you tried anything to ease this problem?
If you don't get this problem corrected, do you think it will get worse in the next 5 - 10 years?
On a scale of 1 to 10 (10 being the highest), what is your commitment to getting this problem corrected and improving your child’s health? (Circle)

Very Low
Very High
Birth - 4 Years
5 - 12 Years
Vaccinations
Reactions to vaccinations?
Has your child experienced any of the following?
Which of the problems that you’ve checked off are you most concerned about?
Is there anything else you feel we should know?
By signing here, I verify that the above information is true and accurate regarding my child’s health history.
Today's Date: 19 Nov 2019