FV Ingles Kids - Mediterráneo Quiropráctica %

FV Kids (English)

Child's name

Child's lastname

Parents' names

Child's date of birth

Birth order

Name(s) & age(s) of sibling(s)

Contact telephone number

Address, city and zip code

E-mail

Best way and time to contact you

Child's weight and height

Select the option that best represents your reason for caring for your child.

If you have selected "symptomatology", please explain the reason for your selection

When did his/her health problems begin and for how long?

What makes it better?

What makes it worse?

Is your child receiving care from other health professionals?

Yes

If yes, please name them & their speciality

What medication has your child taken/ is currently taking?

Has your child had any antibiotics?

Does your child take any vitamin or mineral supplements?

Has your child had any medical treatment/ scans/ x-ray/ surgery?

Does your child have any congenital disorder?

Has your child had any vaccinations?

Has your child broken/ fractured any bones?

Any known allergies?

Does your child have a good diet?

Wich sports activities does your child do?

How would you describe your child's activity level?

Regular bowel movements?

How would you describe your child's emotional/ mental health?

Do you have any other concerns for your child, or any other information you think might be relevant?

Family history of medical problems

Have you ever visited a chiropractor?

Yes

Gestational duration (in weeks)

Did you have falls during pregnancy?

Did you have ultrasounds during pregnancy?

Did you have invasive procedures (e.g., amniocentesis)?

Yes

Did the mother smoke during pregnancy?

Yes

Did you drink alcohol during pregnancy?

Yes

Did the mother take medication during pregnancy?

Yes

Did the mother use drugs during pregnancy?

Yes

Were you sick during pregnancy?

Yes

Any maternal illness or medical treatment during pregnancy?

Did you take any vitamins? Indicate which one(s)

Rate emotional stress during pregnancy

How long did the delivery and expulsion process last?

Did the mother receive medication during the delivery process?

Do you remember your child's AGPAR test score at birth?

How much did your child weigh at birth?

Were there any complications during delivery?

Did your child need any of the following care?

Did your child show any signs of childhood trauma?

Was your child in the ICU?

Does your child have a preferred sleeping position?

Was your child breastfeed?

Yes

If yes, for how long?

If breast-feeding, do you prefer to breast-feed on one side only?

Yes

Did the mother have difficulty breastfeeding?

Yes

Has the mother taken antibiotics?

Began foods at age:

Formula introduced at age:

Introduction of cow's milk at age:

Regurgitates or regurgitated?

Yes

Age the child began nursery:

Number of hours in front of TV/ iPad/ phones/ computers a day:

Has he/she fallen off the bed, changing table or sofa?

Yes

At what age did your child: Sit unaided

At what age did your child: Stand unsupported

At what age did your child: Crawl

At what age did your child: Walk unaided

At what age did your child: Speech

At what age did your child: Self dressing

Was there any difficulty in mother-child bonding?

yes

Do you consider that your child sleeps well? Consider the quality of his/her sleep

Good

Normal

Low

Does he/she have behavioral problems?

Yes

What would you like to achieve with chiropractic care?

In compliance with the Regulations UE 2016/679 27 April 2016, on the protection in relation to the treatmen and free circulation of personal data, and following the recommendations and instructions issued by the Spanish Agency for Data Protection (AEPD),

You are informed that:

The personal data requested and provided will be incorporated into a privately owned file whose manager and recipient is Mediterraneo Quiropráctica.

Only those data strictly necessary to properly manage the chiropractic service, contact and the issuance and treatment of invoices will be requested, and it may be necessary to collect personal data from third parties such as legal representatives, guardians or persons in charge designated for this purpose.

All the data collected will have a commitment to confidentiality and the legally established security measures and under no circumstances will they be transferred or processed by third parties, physical or legal, (except our advice for billing), without prior consent of the patient, legal representative, tutor or person in charge, except in those cases where it is essential. - Once the relationship between Mediterraneo Quiropráctica and the patient has ended, the data will be archived and kept for 6 years from the last visit. After this period of time they will be destroyed or failing that they will be returned entirely to the patient or legal authorized.

I express my consent that the data I provide can be included in the file of Mediterraneo Quiropráctica, in order to properly manage the chiropractic service, contact and treatment of invoices. I also declare that I have been informed of the possibility of exercising the rights of access, rectification, cancellation and opposition, requesting it in writing to Mediterraneo Quiropráctica

at Calle Frigiliana nº16 29003, Malaga or by email to info@mediterraneoquiropractica.com

I have read and agree to the Terms and Conditions and the Privacy Policy

I consent that this website stores my submitted information so that they can respond to my query.