Progress Form (0-5 years)

Congratulations, your child has reached their progress visit.

Please double check that you are completing the correct attachment from the email.

Completing this form provides us with the necessary information to assess your child's progress to date under chiropractic care. It is also an opportunity for you and your chirorpactor to reflect on your goals, establish new ones and re-evaluate your child's care plan moving forward.

Personal Information

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Has your child's contact details changed since their last report? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Update contact details

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mobile {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Home Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Has your child's emergency/ guradians contact details changed since their last report? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Emergency/ Guardian Contact

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Relationship to minor: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Best day time contact number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Current Health

Please elaborate: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

What do you hope to achieve under chiropractic care at Habitat moving forward? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

How do you rate your Childs OVERALL health at present (scale 1-10) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does your child currently experience any of the following? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Since their last report, has your child experienced any of the following? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does their current health status impact any of the following? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Development

Please indicate ALL milestones that your child has met to date: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lifestyle

Is your child currently on any medications or prescribed drugs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is your child currently on any supplements, vitamins or herbs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list and explain what they are used for: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Is your child exposed to, or experiencing any of the following? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Chiropractic

What is your current understanding of chiropractic and what we do as Chiropractors? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you know what vertebral subluxation is in chiropractic? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please define: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Any comments or additional information that you would like to add? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Agreement

I have reviewed and certify that all the information that I have reported above is true and to the best of my knowledge.

Full name (name of guardian): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Relationship to minor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date Signed: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}