Holdom Chiropractic & Wellness Centre
111-2251 Holdom Ave
BURNABY, BC V5B 0A2
(604) 298-1777
dcronuppal@hotmail.com

Thank you for taking the first in improving your child's overall well being.

 

So why would a child have a spine and nervous system problem? Traumatic births. Learning to walk. Slips. Falls. The list is endless. Yet, because children have such an adaptive capacity, these problems are often brushed off as “growing pains” or just a “phase they’re going through.”

“As the twig is bent, so grows the tree.”

Many patients report that chiropractic care has been helpful for colic, ear infections, erratic sleeping habits, bedwetting, scoliosis, “growing pains” and many other common childhood health complaints.

The concern that many parents have is that chiropractic adjustments will be too forceful. They mistakenly think that their child will receive adjustments like ones they receive. Not only are adjusting techniques modified for each person’s size and unique spinal problem, an infant’s spine rarely has the long-standing muscle tightness seen in adults. This makes a child’s chiropractic adjustments gentle.

Knowing exactly where to adjust, newborns and infants are adjusted with no more pressure than you’d use to test the ripeness of a tomato. Many parents have commented that they see almost instant improvements in the well-being of their child.

 

Thank you with entrusting us with the care of your child.

Holdom Chiropractic & Wellness Centre
111-2251 Holdom Ave
BURNABY, BC V5B 0A2
(604) 298-1777
dcronuppal@hotmail.com
First Name
Last Name
Address
City
Postal
Gender
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
Holdom Chiropractic & Wellness Centre
111-2251 Holdom Ave
BURNABY, BC V5B 0A2
(604) 298-1777
dcronuppal@hotmail.com
Complications during pregnancy?
Ultrasounds during pregnancy?
Medications during pregnancy?
Cigarette/alcohol use during pregnancy?
Location of birth:
Birth intervention performed:
Delivery medication?
Delivery complications?
Birth Weight
APGAR Scores
Birth Length
Holdom Chiropractic & Wellness Centre
111-2251 Holdom Ave
BURNABY, BC V5B 0A2
(604) 298-1777
dcronuppal@hotmail.com
Name of Pediatrician
Date of Last Visit
Reason
Treatment
At what age, in months, was the following introduced?
Solids:
Cows milk:
At what age was your child able to (in months):
Respond to sound
Hold head up
Crawl
Sit



Respond to visual stimuli
Stand Alone
Walk Alone


Personal Illness History
Holdom Chiropractic & Wellness Centre
111-2251 Holdom Ave
BURNABY, BC V5B 0A2
(604) 298-1777
dcronuppal@hotmail.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Holdom Chiropractic & Wellness Centre
111-2251 Holdom Ave
BURNABY, BC V5B 0A2
(604) 298-1777
dcronuppal@hotmail.com
Number of doses of antibiotics your child has taken:
Last 6 months: Since birth:
Number of doses of other prescription medications your child has taken:
Last 6 months: Since birth:
Child's daily habits (skip any questions that do not apply):
Hours of sleep per night (1-24)
Child's exercise
Average amount of time spent watching TV, playing video games, or using a computer per day:
How often does this child consume:
Caffeine Drinks:
Sugars/sweets:
Dairy Products
Wheat Products
Fruits/Vegetables
Water as a beverage:

Holdom Chiropractic & Wellness Centre
111-2251 Holdom Ave
BURNABY, BC V5B 0A2
(604) 298-1777
dcronuppal@hotmail.com
Present problem:
First occurrence of condition
Did something specific cause this condition? (please describe)
Since the problem started, is it:
Does anything make it better?
Does anything make it worse?
Other health professionals seen for this problem (please list names and dates if applicable)
Chiropractor
Medical Doctor
Other
Holdom Chiropractic & Wellness Centre
111-2251 Holdom Ave
BURNABY, BC V5B 0A2
(604) 298-1777
dcronuppal@hotmail.com
Please read the following carefully before signing.

 

INFORMED CONSENT TO CHIROPRACTIC CARE

 

HOLDOM CHIROPRACTIC

 

 

 

Doctors of chiropractic who use manual therapy techniques are required to advise patients that there are or may be some risks associated with such treatment. In particular you should note:

 

 

 

A)       While rare, some patients may experience short term aggravation of symptoms, rib fractures or muscle and ligament sprains or strains as a result of manual therapy techniques;

 

 

 

B)       There are reported cases of stroke associated with many common neck movements including adjustment of the upper cervical spine. Present medical and scientific evidence does not establish a definite cause and effect relationship between upper cervical spine adjustment and the occurrence of stroke. Furthermore, the apparent association is noted very infrequently. However, you are being warned of this possible association because stroke sometimes causes serious neurological impairment, and may on rare occasion result in injuries including paralysis. The possibility of such injuries resulting from upper cervical spinal adjustment is extremely remote;

 

 

 

C)       There rare reported cases of disc injuries following cervical and lumbar spinal adjustments although no scientific study has ever demonstrated such injuries are caused, or may be caused, by spinal adjustments or chiropractic treatment.

 

 

 

Chiropractic treatment, including spinal adjustments, has been the subject of government reports and multidisciplinary studies, conducted over many years and has demonstrated to be effective treatment for many neck and back conditions involving pain, numbness, muscle spasm, loss of mobility, headaches and other similar symptoms. Chiropractic care contributes to your overall well being. The risk of injuries or complications from chiropractic treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms.

 

 

 

I acknowledge I have discussed, or will have the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in particular (including spinal adjustments) as well as the contents of this Consent.

 

 

 

I consent to the chiropractic treatments offered or recommended to me by my chiropractor, including spinal adjustments. I intend this consent to apply to all my present and future chiropractic care.

 

 

 

Dated this _________________ day of _____________________________, 20____

 

 

 

 

 

        _________________________________                ______________________

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 18 Jun 2018