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Bayview Village Wellness Centre 201 – 2901 Bayview Avenue North York, ON M2K 1E6

416.221.7724 www.bayviewwellness.com

Dr. Ed Lubberdink, D.C. Dr. Tonya Luby, D.C. Dr. Amanda Graham, D.C. Dr. Stacey Smith, D.C.

Pediatric New Patient Questionnaire

Child’s Name: Date: Parents’ Names: ___________________________ & Address: City: Postal Code: Home Phone: Cell Phone: Work Phone: Weight(current): Height(current): Sex: Male q Female q D.O.B.: / / Month Day Year Has your child ever received Chiropractic care? YES NO

Purpose for contacting us: Wellness Check? q Health Concern? q

Condition description: ____________________

Is the condition getting better or worse: _____________________________________________

Other doctors seen for this condition: Yes q No q

If yes, Doctor’s names and prior treatments:

Other health problems:

Family history:

Number of anti-biotics your child has taken over the last 6 months:

Total during his/her lifetime?

Other medications:

HISTORY OF BIRTH

What was child’s gestational age at birth? weeks

Birth weight lbs oz Birth length inches

Was your child’s birth (circle one) at home in a birthing centre in a hospital ?

Was the birth attended by (circle one) OBGYN midwife ?

What was the duration of the labour and birth? hours

Were there any complications? Yes q No q If yes, please explain: _______________________

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Any assistance which was used during the birth:

Forceps q Vacuum extraction q C-section q Episiotomy q

Was labour: spontaneous q induced q ?

Were medications or epidurals given to the mother during birth? Yes q No q

If yes, what was given

APGAR score: at birth /10 After 5 mins /10

Complications during pregnancy? Yes q No q If yes, list:

Ultrasounds during pregnancy? Yes q No q If yes, total number:

Medications during pregnancy Yes q No q If yes, list:

PHYSICAL STRESSORS Any traumas to the mother during pregnancy? (ie. Falls, accidents, etc.) Yes q No q

Any evidence of birth trauma to the infant? (please check)

o Bruising

o Stuck in birth canal

o Respiratory depression

o Odd shaped head

o Fast or excessively long birth

o Cord around neck

Any falls from couches, beds, change tables, etc? Yes q No q_____________________________

Any traumas resulting in bruises, cuts, stitches or fractures? Yes q No q __________________

Any hospitalizations or surgeries? Yes q No q __________________________________________

Is / has your child been involved in any high impact or contact-type sports (soccer, hockey, football, gymnastics, baseball, cheerleading, martial arts, etc)? Yes q No q

Is a school backpack used? Yes q No q Is it (circle one) heavy light

CHEMICAL STRESSORS

Was this child breast-fed? Yes q No q If yes, how long?___________________________________

Introduction of cow’s milk at what age?

Began solid foods at what age? __________Type of foods?

Any food intolerance? Yes q No q Type? _________________________________

During pregnancy, did the mother

smoke? Yes q No q How much? drink? Yes q No q How much?

Any supplements taken during pregnancy? Yes No

Number of anti-biotics your child has taken over the last 6 months:

Total during his/her lifetime?

Other medications:

Vaccination History Vaccinations and age given

Any negative reactions? Yes q No q_________________________________________

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EMOTIONAL STRESSORS: Any difficulties with lactation? Yes q No q Any problems with bonding? Yes q No q Any behavioural problems? Yes q Noq Any night terrors, sleep walking, difficulty sleeping? Yes q No q Age of child when began day care: ______________ Average number of hours of television per week? Do you feel your child’s social and emotional development is normal for their age? Yes No

DEVELOPMENTAL HISTORY:

During the following times your child’s spine is most vulnerable to stress and should be routinely checked by a doctor of chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference).

At what age was your child able to:

Respond to sound Cross crawl

Respond to visual stimuli Stand alone

Hold head up Walk alone

Sit up

Childhood diseases: Chicken pox Yes q No q Age:

Measles Yes q No q Age:

Mumps Yes q No q Age:

Whooping cough Yes q No q Age:

Other Yes q No q Age:

AUTHORIZATION FOR CARE OF A MINOR:

I, , hereby authorize the Bayview Parent/guardian’s name Village Wellness Centre and its doctors to administer care to my son/daughter as they

deem necessary. I clearly understand that I am responsible for payment of all fees

charged by this office.

Print Sign Date Witnessed by

OFFICE POLICY

To our patients:

Thank you for seeking Chiropractic care as a method to evaluate your conditions and to restore your health naturally. Shortly you will be interviewed by the Doctor. After reviewing your completed, confidential health questionnaire, should the Doctor feel your conditions would best be treated by another health practitioner, you will be advised and referred accordingly. However, should your condition fall within the scope of Chiropractic, a thorough consultation will be undertaken to document your case history. A comprehensive Chiropractic examination will then be conducted to determine the cause of your problem(s). The examination consists of:

• Postural Analysis • Physical Examination • Orthopaedic/Neurological Examination • Radiology

After this initial session, examination findings will be interpreted. During your second visit, the Doctor will explain the findings and will make recommendations for the Chiropractic care required in your particular case. Please note: In order to achieve the maximum benefit from your Chiropractic care, it is necessary to follow the care plan outlined by your Doctor.

FEE SCHEDULE

Procedure Patient Fee New Patient Consultation and Examination 99.00

New Patient X-Rays included Progress Exam 30.00

Computerized Muscle Testing 25.00 Adjustments – Adult 45.00

Adjustments – Children 30.00 Re-Examination and X-Rays 114.00

Fees are due when services are rendered. There will be a charge of $5.00 for each missed

appointment unless 6 hours notice is given.

I have read and understood the above, and will be bound to the terms and conditions outlined. ________________________________ _____________________________ ___________________ (Print name) (Signature) (Date)

CONSENT FOR XRAYS

Dr. Ed Lubberdink Dr. Tonya Luby Dr. Stacey Smith Dr. Amanda Graham Doctors of Chiropractic

For Women This is to certify, to the best of my knowledge, that I am not pregnant and the Bayview Village Wellness Centre has my permission to take x-rays. ________________________________ _____________________________ ___________________ (Print name) (Signature) (Date) I am presently using: Birth Control Pills ______________________ IUD _________________________________ Within 10 days of my period _____________ Or I will assume responsibility for any effect on a fetus potentially present for one of the following: Hysterectomy ___________________ Tubal Ligation __________________

Bayview Village Wellness Centre 2901 Bayview Avenue, Suite 201 Toronto, Ontario M2K 1E6 Tel: (416) 221-7724

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