Communication Form - KIDS - Healthy Kids Nurtured by Nature

Referrer Details

Referring Clinic*

Practitioner First Name*

Practitioner Surname*

Referring Practitioner Email*

If you are not the above Practitioner please complete your name below.

Other Practitioner First Name

Other Practitioner Surname Name

Patient Details

Child's First Name*

Child's Last Name*

Child's Date Of Birth

Parent First Name*

Parent Surname*

Mobile*

Email*

Confirm Email*

Degree of Urgency*

Symptoms

Unsettled Baby

Yes
No

Incorrect Swallow Pattern

Yes
No

Learning Difficulties

Yes
No

Colic Symptoms

Yes
No

Incorrect Chewing Patterns

Yes
No

Narrow Upper Arch

Yes
No

Communication Difficulties

Yes
No

Poor Lip Competence

Yes
No

Cross Bite

Yes
No

Feeding Swallowing Difficulties

Yes
No

Bedwetting

Yes
No

Crowded Teeth

Yes
No

Mouth Breathing

Yes
No

Low Tone

Yes
No

Difficulty with Breast Feeding

Yes
No

Snoring

Yes
No

Poor Head Control

Yes
No

Traumatic/Complications During Birth

Yes
No

TMJ Dysfunction

Yes
No

Poor Posture

Yes
No

Tongue thrust

Yes
No

Thumb/Finger/Dummy Sucking Habits

Yes
No

Incorrect Tongue Resting Position

Yes
No

Family History

Pre-Treatment Recommendation:

Lactation Consultant Date

Started OM Exercises Date

Paediatric Chiropractor Date

3 week Review Date

Speech Pathologist Date

Dentist Date of Release

Referring Practitioner Comments