Greenspan Chiropractic Fitness

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Children's Health Survey

We would like to thank you in advance for filling out our children's survey. We respect your privacy. This information is only for review by Dr. Greenspan.

Parent's Name:
Parent's E-mail:
(required)
Address:
City:
State:
Zip:
Home Phone:
Child's Name:
Child's Age:
Address (if different):
Phone (if different):

REGARDING YOUR CHILD
Do you feel your child could do better in school?
 YesNo
Has your child ever been hard to control?
 YesNo
Has your child ever had a tantrum?
 YesNo
Has your child ever had a problem concentrating?
 YesNo
Has your child ever not liked a subject?
 YesNo
Does your child have poor attention?
 YesNo
Is your child afraid of taking tests?
 YesNo
Does your child ever bite another?
 YesNo
Does your child not want to go to school?
 YesNo
Does your child exaggerate he/she gets hurt?
 YesNo
Does your child have a learning disability?
 YesNo
Does your child not get along with other children?
 YesNo
Does your child have any health problems (i.e. bedwetting)?
 YesNo

REGARDING YOUR RELATIONSHIP WITH YOUR CHILD
Do you find yourself irritable when you are with your child?
 YesNo
Do you find yourself fatigued when you are with your child?
 YesNo
Do you get headaches when you are with your child?
 YesNo
Do you find yourself grinding your teeth?
 YesNo