Kids Need Chiropractic Too!

By Peter Fysh, DC
Pediatric Patient Survey

This month we are devoting this column to what we consider to be a vitally important study, one which may help to shape the continuing future of chiropractic care for the pediatric patient.

Published below is a survey form which is designed to help determine which childhood conditions are most commonly seen by chiropractors, and what is normal and customary care for chiropractic pediatric patients.

This survey is prompted by requests from many doctors of chiropractic who told us that they are concerned that chiropractic care for children is not being adequately funded by insurance companies, and is being further limited by third-party interests whose main concern is cost containment.

To gain the required accuracy of results for this survey and for maximal effect, it is critical that a large number of chiropractors complete the survey. Doctors who read this pediatric column regularly now have a chance to have direct input into the future of managed pediatric chiropractic care.

All that is necessary is to photocopy the survey form from this page then answer all the questions and return the survey promptly. It will take your staff a few minutes, but it may help ensure that children from those families who depend upon insurance coverage for continued chiropractic care can continue to bring their kids to your office. All replies will remain anonymous.

Please help us take this important step toward developing a consensus on appropriate care for our pediatric patients.

(who were under 16 years of age)
The purpose of this form is to determine the most common reasons why pediatric patients are treated by chiropractors.
Please make an entry for each patient that you treated last month, who was under 16 years of age.
Age Sex Chief Complaint QVs Req'd Vert.Levels Adjusted Results of TMT TechniqueUsed
5 M Earache 5 C1,C2 R D

Upon completion please return to:

Result of Treatment

Peter Fysh, DC   R = resolved D = discontinued
5823 Killarney Circle      
San Jose, CA 95138   U = unresolved M = maint. care

Instructions for Completing the Form

Please use the following guidelines for entering data relating to the pediatric patients that you treated last month (under 16 years of age).


Enter the age in years. For infants that have not reached their 1st birthday, enter the age as 0.


Enter M or F.

Chief Complaint

Enter the major presenting complaint for which the child was brought to your office. Examples: enter earache, not otitis media; sore throat, not tonsillitis. If the child presented for a routine spinal evaluation and a problem was detected during that examination, enter that problem as the chief complaint.

OVs Req'd

Enter the number of office visits required for this patient during the past month. Count the case history and physical examination as one visit. If treatment was performed at the same office visit as the case history and physical exam, the entire procedure should still be counted as one visit.

Vert. Levels Adjusted

Enter the spinal segments which were adjusted for this child during the month. If the entry panel is not large enough, use the line below.

Technique Used

Enter a letter from the following list to describe the selected spinal adjusting technique used for this child.

A = Activator
D = Diversified
G = Gonstead
S = Sacro-occipital technique

O = Other (if Other, please enter the name of the technique used in the right margin of the form)

Results of Treatment

Enter a letter from the following list to describe the result of the month's treatment on this child.

R = Resolved. Use this entry if the chief complaint, originally identified, has been resolved.

U = Unresolved. Use this entry if treatment of the child's complaint is still ongoing.

D = Discontinued. Use this entry if the treatment program was discontinued, follow-up visits were not kept or were cancelled. If a parent called to cancel a follow-up visit, and advised that the problem was resolved, then you should use the letter R.

M = Maintenance Care. Use this entry if the original complaint has resolved and the child has been transferred to a well-child program.

Peter Fysh, DC
San Jose, California

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