Last 4 digits only of Parent Social Security Number
Parent's Date of Birth?
Last 4 digits only of Child's Social Security Number
Gender of Child (Female or Male) and Date of Birth?
Height of Child
Weight of Child
Parent Email *
Parent Cell Phone
Parental Relationship Status Single Married Other
Number of Children 0 1 2 3 4 5 6
Emergency Contact, Relationship & Cell Phone?
What is parent's occupation
Has the child ever experienced Craniosacral Therapy or Chiropractic? Yes No
Date of last pediatric visit & description of what was done?
Is the child currently diagnosed with any condition, please describe
Is the child currently under regular care or undergoing treatment, please describe
Primary reason for today's visit?
Are you aware of any injury this child may have sustained since birth? No Yes
If yes, please describe
Describe the child's short term health goals
Does the child have all vaccines? Yes No
Does the child wear glasses or contact lenses? Yes No
Does the child have speech impairment? Yes No
Does the child/did the child have Tongue Tie/Lip Tie? Yes No
Does the child have a hearing deficiency? Yes No
Does the child have a lisp? Yes No
Does the child sleep through the night? Yes No
Does the child get sick often? Yes No
If yes, please describe
Does the child complain of headaches? Yes No
If so, how often? daily once/week couple times/month
Does your child complain of pain? Yes No
If yes, where? Head Neck Back Legs Feet Arms/Hands
Does the child have any food allergies? Yes No
If yes, please describe
Has the child had extensive dental work (braces, pulled teeth, etc.)? Yes No
Car accident falls or injuries? Yes No
If yes, please describe
Does the child have arthritis? Yes No
If yes, please describe
Does the child have any heart problems? Yes No
If yes, please describe
Does the child have any spinal problems? Yes No
If yes, please describe
Does the child ever arch their neck or back? Yes No
Does the child take any prescribed medications? Yes No
If yes, please describe
Has the child ever been hospitalized? Yes No
If yes, please describe
Is the child active or play sports on a regular basis? Yes No
If yes, please describe
Is the child receiving any other care such as chiropractic, naturopathy, homeopathy, acupuncture, nutritional, physical therapy, hypnotherapy ? Other? Yes No
If yes, please describe
Are there any physical or mental conditions of which Dr. Kaminsky should be aware of? Yes No
If yes, please please describe
Mom Pregnancy History, where there any fertility issues? Yes No
If yes, please describe
Did Mother exercise during pregnancy? Yes No
Were there any notable mental or physical stresses during pregnancy? Yes No
Name of practitioner who delivered the child
At how many weeks was your child born?
What was the child's birth weight?
What was the child's birth height?
Baby's APGAR score at birth and after 5 minutes?
Please provide any other pertinent / additional information about your labor & delivery
Is / was your child breast fed? If so for how long?
Did you have difficulty with breastfeeding? Yes No did not breast feed
Did the child eat formula? Yes No
If yes, please describe how you incorporated it, how long was the child on it, and at what age did you stop?
Please list the child's hospitalization & surgical history
Please provide any additional information you would like to share with Dr. Kaminsky
