We are open 7 days a week from 6am - 8pm
Call/TEXT: 613 237 3306
Hit enter to search or ESC to close
0
Our Clinic
Patients
Visiting the Centre
Clinic Fee Schedule
Do I Need a Referral?
Book an Appointment
Patient Forms
Your Report of Findings
Photos and Videos
Videos
Careers – Join our Team!
Services
Chiropractic
Active Release Technique
Acupuncture
Cranial Therapy
Naturopathic Care
Physiotherapy
Orthotics Ottawa
Gait Analysis for Better Foot Health
Massage Therapy
Additional Services and Articles
What We Treat
Products & Supplements
Patient Stories
BOOK AN APPOINTMENT
0
was successfully added to your cart.
Cart
New Pediatric Patient Questionnaire (Ages 0-2)
Step
1
of
5
- Personal Information
0%
Parent / Guardian Information
Name of Parent or Guardian
*
First
Last
Email
*
Email Communication
*
I consent to receive electronic communication messages from Back to Health & Wellness Centre.
I do not consent to receive electronic communication messages from Back to Health & Wellness Centre
Phone# - Home or Cell
*
Phone# - Work
Address
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Referred by
*
Please provide the name of who you were referred to us by, if applicable.
Child Information
Name of Child
*
First
Last
Address
Address is different than Parent / Guardian
Child's Address
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Sex
*
Gender
*
How did you find out about our clinic?
*
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
During pregnancy, were you on any medication?
*
Yes
No
What medications were you taking during pregnancy?
*
Did you smoke during pregnancy?
*
Yes
No
Did you have back pain during pregnancy?
*
Yes
No
Were you physically ill during pregnancy? (Colds, flu, allergies, German measles, etc.)
*
Yes
No
Please list any physical illness you endured.
*
Approximately, how long was labour?
*
:
Was labour chemically induced?
*
Yes
No
Was labour Doctor assisted?
*
Yes
No
Was a C-section performed?
*
Yes
No
Were forceps used?
*
Yes
No
Did the doctor have his hands on the infant?
*
Yes
No
How severe was your pain/discomfort during labour and delivery?
*
Low
Medium
High
Were there any complications before or during delivery?
*
Yes
No
Please explain any complications.
*
Was the baby premature?
*
Yes
No
What was his/her age at birth?
*
What was his/her weight at birth?
*
Has your child suffered any of the following health problem?
*
Headaches
Allergies
Ear problems
Sleeping disorders
Breathing Problems
Fatigue
Irritability
Hyperactivity
Frequent Colds
Flu
Bloody Noses
Meningitis
Diarrhea
Constipation
Colic
Rashes
Milk/Lactose Intolerance
Bed Wetting
Digestive Problems
Other
Please select all that apply.
Please describe any ''other" health problems.
*
Is your child accident-prone?
*
Yes
No
Please describe your child's tendency to be accident prone.
*
Has the child had any falls down steps?
*
Yes
No
Please describe the fall(s).
*
Has your child ever fallen from heights?
*
Yes
No
Please describe any fall(s) from heights.
*
Has your child been involved in a motor vehicle accident?
*
Yes
No
Please describe the motor vehicle accident(s).
*
Has your child ever been hospitalized or had surgery?
*
Yes
No
Please describe any hospitalization or surgery.
*
Does your child suffer from allergies/sensitivities (environmental, foods, drugs, etc.)?
*
Yes
No
Please describe any food allergies/sensitivities.
*
Has your child received all childhood vaccinations?
*
Yes
No
Does your child get regular flu vaccinations?
*
Yes
No
If there have been complications from any vaccinations, please describe.
*
Date of last Annual Physical Exam/Blood Test
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Date of last Antibiotic Use
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Reason for last Antibiotic Use
*
Diet
Does your child eat or come in contact with any of the following?
*
Aluminum pans
Plastic tupperware
Microwave
Air fresheners
Scented body products
Fried foods
Fast foods
Refined/processed food
Candy
Artificial sweeteners
Luncheon meats
Margarine
Does your child have any dietary restrictions? (Vegetarian, religious, etc.)
*
Yes
No
What dietary restrictions do they have?
*
On average, how does your child eat their meals?
*
With family around the table
In front of the TV
On the run
Restaurant
Fast food
Check all that apply.
How often does your child eat at a restaurant?
*
never
rarely
sometimes
often
always
How often does your child eat fast food?
*
never
rarely
sometimes
often
always
Please describe what your child typically eat in one day:
Breakfast
*
Lunch
*
Dinner
*
Snacks
*
Food Likes and Cravings
*
Water (cups per day)
*
Milk (cups per day)
*
Lifestyle
How many hours does your child sleep daily?
*
1
2
3
4
5
6
7
8
9+
Does your child have problems sleeping?
*
Yes
No
Does your child wake feeling rested?
*
Yes
No
Sometimes
Does your child have a bowel movement daily?
*
Yes
No
Does your child suffer from headaches?
*
Yes
No
If your child suffers from headaches. Please describe.
*
Has your child ever had any broken bones or had sprain injuries?
*
Yes
No
Please describe any breaks or sprain injuries.
*
Is your child on any medication?
*
Yes
No
Please list type of medication and dosage.
*
Has your child had a scoliosis examination by an approved scoliosis determination clinic?
*
Yes
No
Please provide details about the scoliosis examination.
*
Is your child hyperactive?
*
Yes
No
Please describe the hyperactivity.
*
Does your child have a learning disorder?
*
Yes
No
Please provide details about their learning disorder.
*
Does your child have poor posture?
*
Yes
No
Please provide details on their poor posture.
*
Does your child have any problems associating with friends?
*
Yes
No
Please explain any problems associating with friends.
*
Is your child nervous or has anyone suggested that your child was nervous?
*
Yes
No
If your child displays nervous behaviour, please explain.
*
Does your child have asthma?
*
Yes
No
Please provide details about their asthma.
*
If you could improve one aspect of your child’s health or behaviour, what would it be?
*
Search Products
Search for:
Search
Product Categories
Aches, Strains & Pains
Acid - Base Balance
Adrenal Support & Stress
Allergies & Sinuses
Antioxidants
B-Vitamins
Back Braces/Supports
Biofreeze & Ice Packs
Bone & Joint Health
Cardiovascular & Circulatory Health
Concussion & Cognitive Health
Digestive Health
Drainage & Swelling/Inflammation
Exercise & Strengthening
Fish Oils
Foot Care
Hormone Regulation
Iron
Knee & Ankle Braces/Supports
Liver Support & Detoxification
Magnesium
Mood & Emotion Regulation
Multi-vitamins & Minerals
Neck Braces/Supports
Orthotics
Pillows
Posture
Probiotic Support
Protein
Respiratory & Immune Health
Sleep Aids
Sports Performance
Thyroid Support
Uncategorized
Visual Aids & Eye Drops
Vitamin C
Vitamin D
Wrist & Elbow Braces/Supports
Zinc
We are open 7 days a week from 6am - 8pm
Our Clinic
Patients
Visiting the Centre
Clinic Fee Schedule
Do I Need a Referral?
Book an Appointment
Patient Forms
Your Report of Findings
Photos and Videos
Videos
Careers – Join our Team!
Services
Chiropractic
Active Release Technique
Acupuncture
Cranial Therapy
Naturopathic Care
Physiotherapy
Orthotics Ottawa
Gait Analysis for Better Foot Health
Massage Therapy
Additional Services and Articles
What We Treat
Products & Supplements
Patient Stories
BOOK AN APPOINTMENT
Call/TEXT: 613 237 3306