Cohasset Family Chiropractic - Child Case History

CHILD CASE HISTORY
Personal Data
Date

Month Day Year
Date
Name

First Name Last Name
Birthday

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Parent Cell
Please enter a valid phone number.
Parent Work
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Ages of Siblings
Parent Name(s) and Email(s)
Who referred you to our office?
Please check any of the following statements that describe(s) your current goals for your child's health and well being?

I am only concerned about relief of a particular symptom I am concerned about relief of a particular symptom, and preventing its return I want my child to perform at the highest capacity
CAUSE

The human body is designed to be healthy. The primary system in the body which coordinates health is the nervous system. The healthy function of every cell, every system, and every organ is dependent upon the integrity of the nervous system. The bones of the skull and vertebrae of the spine house and protect the central nervous system.

From the birth process until the present, events have occurred in your child’s life which may have caused interference and damage to this delicate system. Physical, emotional, and chemical stresses common to our contemporary lifestyles can result in misalignment and damage to the spinal column. This interference is called the Vertebral Subluxation Complex.

This form will help reveal the causes of Vertebral Subluxation which interfere with the optimal function of your nervous system and therefore impair your inborn health and wellbeing.

CHILD CASE HISTORY

Personal Data

The Vertebral Subluxation Assessment