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Spine and Nervous System Health

1. Does your child use hand-held electronics 2 or more hours a day?
Yes
No
2. Does your child have any digestive problems such as constipation or diarrhea?
Yes
No
3. Does your child have poor posture/ rounded shoulders?
Yes
No
4. Does your child experience any of these abnormal symptoms: ear infections, headaches, allergies, colic?
Yes
No
5. Does your child have any issues with focus or attention span?
Yes
No
6. Does your child experience mood swings, stress or anxiety?
Yes
No
7. Does your child have difficulty falling asleep or staying asleep?
Yes
No
Nutrition

1. Does your child eat at least 2 servings of vegetables and 1 serving of fruit daily?
Yes
No
2. Does your child drink at least 1/3 of their total body weight in ounce daily (water, seltzer, beverages with no sugar or sugar substitutes)(ex. 60lb child should drink 20oz)?
Yes
No
3. Does your child eat at least one serving of protein daily?
Yes
No
Fitness

1. How is your child’s weight for their age/height?
Underweight
Average
Slightly Overweight
Severely Overweight
2. How many hours a day is your child physically active?
4 or more hours
2-4 hours
1 hour or less
None
Immunity

1. How often does your child take a vitamin/supplement to increase their immunity?
Never
Monthly
Weekly
Daily
2. How often does your child get sick with a cold or a fever?
Never
Once a year
Once a month
Multiple times a month
3. Does your child have an auto-immune disease?
Yes
No
Sensory Processing

1. Does your child react strongly to certain smells, sounds, or textures (check all that apply)?
Messy/wet play (like paint or glue)
Smells
Sounds
Food Textures
Clothing Textures/Tags
None
2. Does your child have trouble with coordination and bumping into things?
Yes
No
I Would Like More Information

Spinal Wellness
Nutrition
Fitness
Immunity
Sensory Processing
Other (check all that apply)
Positive Psychology
Parental Support (Mom Group)
Occupational Therapy
Working Moms
Please Enter Your Name (parent completing analysis) *
Please Enter Name/Nickname for the Individual the Analysis is being completed *
Gender of Child *
Male
Female
Age of Child *
Newborn to 2 years
2+ to 5
5+ to 11
11+ to 16
Email *
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