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Therapies
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Sports massage
Pre and Post Natal Massage
What Our
Patients Say
Disc damage in tiler
I can walk without pain and can now do certain gardening tasks .....
Slipped disc and Sciatica in young mother
Quality of life at 77!
Headaches in Teenager
Scoliosis improves in child
9 year old boy much happier thanks to HANDLE
The calm atmosphere and skilled attention at The Penn Clinic
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Baby / Child Form
Please fill in all questions in every case
Todays Date
Date of appointment if known
Child's First Names
Child's Surname
Gender
Male
Female
Your Child / Baby's Date of Birth
Birth Weight
Name of Parent or Guardian completing this form
Address
Email:
Best telephone to reach you
Other numbers
GP & Address
Brothers and Sisters (Dates of birth & Birth Weights).
Please detail any problems siblings had.
Who referred you to this clinic?
1. Problems: Reasons why you are bringing your child/baby.
Reasons why you are bringing your child / baby.
2. What do you hope to gain from your visit?
3. Does your child have any favourite positions or commonly make any particular movements?
4. Allergies, Please list
5. Other therapies or Treatments List those currently used and provide approximate dates for those utilized in the past.
6. Medication/Drugs
for baby / child now (Include Skin applications and creams) Give Medication Name | When | What for
7. Past Medication / Drugs
Give Medicaton Name | When | What for
8. Vaccinations
Baby
8w
12w
16w
Preschool
All
Some
School
All
Some
Teen Girls
(HPV)
Yes
Teen Boys & Girls
(Booster & Men C)
Both
One
None
9. Reactions to vaccinations
Please describe
10. Illnesses (Including infections and any medication given)
11. Accidents
12. Hospital Admissions, casualty, tests, treatments, operations (including circumcision)
13. Family General Health (parents, grandparents, aunts and uncles).
14. Family History of:
Asthma
Eczema
Hayfever
Diabetes
15. Smokers in the household & Number of cigarettes per day for each smoker?
16. Pets in the house?
About the mother during pregnancy
17. Mother's Age
18. IVF?
Yes
No
Problems?
19. How did you feel physically & emotionally during pregnancy?
20. Excessive stress or trauma? : Describe
21. Illnesses? : Describe
22. Bed Rest : Describe
23. Toxaemia : Describe
24. Any drugs taken? : Describe
25. Any issue that needed medical attention during pregnancy?
26. Any other issues during pregnancy?
27. Tests during pregnancy:
Ultrasound Scan
Nuchal Scan
X-ray
Amniocentesis
Chorionic Villus Sampling
Alpha Foetal Protein
28. Describe babies movements in utero:
29. Babys head engaged: When?
Patients Birth (a copy of hospital discharge summary would be helpful)
30. Was baby born on the due date, if not how many days early or late?
31. Birth?
Hospital
Home
32. Onset of Labour
Induced
Spontaneous
Waters broken by midwife
33. Part born first?
Head
Breech
Footling Breech
34. Approximate Length of Labour
1st Stage, 2nd Stage, 3rd Stage
35. Drugs used during labour
36. Was the baby stuck at any stage? Describe
Suction, Forceps, Cord around Neck?
37. Foetal Distress? Describe
38. Planned C-Section (Before birth Started) or Emergency C-Section (After birth started)
39. Oxygen issues before or after birth? Describe
40. If forceps were used where were marks immediately after birth?
Above ears
Level with ears
Below ears
After Birth
41. How long was baby removed before you touched him or her?
42. APGAR Score.
At 1 Minute and at 5 Minutes
43. Time in incubator or NICU - How long?
44. Any noticeable concerns / difficulties at or after birth
45. Multiple pregnancies in utero but not at delivery multiple birth at birth, Birth order?
46. Within the first 30 minutes did the baby:
Tick if Yes.
Cry
Suck
47. Concern about babys head?
48. Head shape changed a lot during the first 24 hours. Describe
49. Baby settled between feeds during first week
50. Ongoing medical treatments / drugs for mum and baby
51. Breastfed or Bottlefed?
Breastfed
Bottlefed
Any Problems?
52. Colic Explain
53. Early sleep issues
54. Introduced solids age
55. Early food issues
56. Weight gain - Percentiles?
57. Bowels
58. Early, frequent startling at sound, touch, light
59. Little or no tummy time
For baby under 2 months, Scroll to the end and click SUBMIT.
60. Floppy head after 2 months
61. Sat unsupported at
62. Rolled at
63. Crawled at
64.
Bum Shuffled
Dragged one leg
Other
65. Walking age
66. No babbling
67. Little eye contact after 4 months
68. Started saying words age
69. Short sentences began age
70. Potty Trained Day and Night?
71. School or nursery (please give the school name; is there anything special about it?)
72. What are your child's special interests or hobbies?
73. Dental History (any problems, treatment or orthodontics)
74. Is your child:
Left Handed
Right Handed
Ambidextrous
Your privacy is important to us - a copy of our privacy policy can be found
here
. By submitting this form you agree to the use and storage of your personal data.
Thank you
Home
About Us
Osteopathy
Cranial Osteopathy
Babies & Children
What do people come with?
Women's Health
Additional
Therapies
Counselling
Exercise and Rehabilitation
Sports massage
Pre and Post Natal Massage
What Our
Patients Say
Find Us
Contact Us
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