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Youth Posture & Spinal Health Check Up Form

I: Basic Information

First name

Last name

Age

Gender

Male

Female

Birthday

Día

Mes

Año

Does your child usually exercise?

More than 3 time a week

1 ~ 2 times a week

Almost never

Height ( input 5'3" means 5 feet 3 inches)

Weight ( lbs)

School Name

Grade

II. Parent / Guardian and Emergency Contact Information

Parent / Guardian Name

Phone

Email

Relationship to Child

Father

Mother

Guardian

Emergency Contact Information

Name

Phone

Relationship to Child:

Father

Mother

Friends

Other

III. Health Status Screening

Has your child been diagnosed with any of the following problems? ( Select all that apply for you)

Does your child currently experience any of the following symptoms ( Select all that apply )

Lifestyle Habits

Average screen time everyday?

Yes, More than 4 hours daily on average

Yes, 2 to 4 hours daily on average

Yes, 1-2 hours

Seldom, less 1 hour every day

Sleeping Posture Habit

Supine

Side

Prone

Not fixed

IV. Additional Information

Past Medical History / Major Surgery History

Please list if your child has any of the following medical history

History of fractures/trauma ( e.g., Spine, Limbs)

History of spinal/orthopedic surgery

Diagnosed with neurological disorders ( e.g., epilepsy, cerebral palsy)

No specific medical history

Other chronic diseases

Is your child currently receiving other treatments

Is your child currently receiving any of the following treatment? ( Select all that apply )

Currently receiving spinal-related medical treatment

Currently receiving physical therapy / Chiropractic treatment

Currently wearing corrective braces ( e.g. Posture corrector, waist support )

No related treatment

Child's daily carrying habits:

Does your child usually carry a single-shoulder bad or a backpack?

single-shoulder bag

backpack

Other

Does your child often cross legs/sit crooked

Always

Sometimes

Never

Parental Expectations or Concerns

What are your main concern for bringing your child today? ( Select all that apply)

Are you willing to learn about follow-up health plans or courses?

Willing

Need further information to decide

Not interested

V. Follow-up Contact Preference

Can we contact you via SMS/email about future health workshop or special offers?

Yes

No

VI. Parental Authorization and informed Consent

VI. Parental Authorization and informed Consent

I understand that this examination is a public welfare assessment, and the results are for reference only and do not serve as a basis for medical diagnosis.

I authorize iRelax.Life Wellness Clinic to conduct a posture and spinal health examination for my child.

I am aware that posture photos will be taken during my child's examination (for assessment reports only, not for other uses).

Signature

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