The Essentials of the Case History
Jeanne Ohm, DC

When taking a case history on a child, especially an infant, the questions we are asking are a bit varied from those we ask the adult patient. Questions that address the birth process and the potential interventions that may have occurred are essential toward proper assessment. Additionally, postural and behavioral considerations, specific to the infant, must be addressed.

The following list of questions is derived from Dr. Heiner Biedermann’s work
(1). The information gathered from these questions will offer you valuable insight in determining the need for specific spinal adjustments in the infant or child.

Long or short duration of delivery?
Presentation at birth?
Forceps or vacuum delivery?
Cesarean delivery?
Visible Immediately after Birth or Later Lateral curvature of the cervical spine?
Rotation of the cervical spine?
Looks only to one side?
Moves only one arm/leg?
Face appears smaller on one side?
Back of the head flattened on one side?
Has a bald spot on the back of the head?

The First Months
Sleeping difficulties during first months, six to twelve months, or later?
Did/does the child often wake up at night?
Fixed sleeping pattern?
Arching of the spine?
Hypersensitivity of the neck region?
Orofacial hypotonus?
Persistent crying? How often?
Problems with breast-feeding on one side or latching on?
Signs of poor digestion and elimination?
General Health Headaches?
Mouth is often open?
Postural adaptations?
Aberrant movement?
Cranial and structural asymmetry?
Sensorimotor development slower than expected?
Delayed language development?
Decreased ability for concentration?
Questionable social integration

Answers to the above questions assist the doctor of chiropractic in assessing aberrant spinal biomechanics and less than optimal nerve system function in the infant and/or child. Combined with a specific spinal exam including segmental motion and muscle palpation and, possibly, X-ray, the doctor of chiropractic will have significant indicators to determine the appropriate care.

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