Biodynamic Cranio Sacral Therapy Baby/ Child Form
Thank you for taking the time to complete this history of your child's birth and possible needs. The information is very beneficial for informing the practitioner prior to our first consultation. Please note that the information on this form will be kept in confidence of the practitioner .
Childs Name
First Name
Middle Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Families Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Parents (please choose)
Living Together
Living Separately
Intention in coming for sessions:
Presenting symptoms or behaviour or baby/child (emotional, physical, relational or other).
How long have these been presenting ?
Any current treatment or medical care ?
Description of baby's birth , including medication, labour interventions, assisted birth i.e forceps, induction, C.section
Premature cutting of umbilical cord (before is stopped pulsating ?)
Is/ was baby breastfeeding?
Description of Mothers own birth (if known)
Description of Fathers birth (if known)
Has baby/child had any medical investigations?
Conception - was your baby planned ? mother & fathers attitude towards news of pregnancy
How was the pregnancy for the mother ? - How was mother's health , diet, emotional well being & exercise during pregnancy
How was the pregnancy for the father? How was father's health , diet, emotional well being & exercise during the pregnancy
How was the fathers attitude towards the developing baby and support of mother?
Does either parent smoke, use drugs or take alchohol?
Please describe any stresses during the pregnancy e.g financial worries, illness , accidents, family problems, absence, bereavement
Baby Medical History : illnesses
Syndrome/ diagnosed conditions
Hospitalisations:
Surgery / Anaesthetics
Dental History
General Health : Diet /feeding
Sleep
Family Structure : who does the baby/child live with?
Please describe the families support network
Further relevant information
Thank you for completing this form!
Submit
Clear Fields
Should be Empty: