Your First Name

Your Surname

Child's Name

Age

Date of Birth

Gender

Your Address

Your Email

Work Telephone

Home Telephone

Mobile Telephone

Health Fund

Reason for requesting a Naturopathic consultation? Brief description of your childs symptoms or condition of concern to you

Please list any medications your child is currently taking (please include dosage)

Is your child allergic to anything (foods, medications, environmental -pollens, chemicals)?

Is your child currently taking any vitamin/mineral supplements, herbs or homoeopathic remedies? (please include dosage)

Please explain any medical conditions your child has been diagnosed with (include age of diagnosis & treatments)

Has your child had any medical tests or investigations performed recently? (why & what were the results?)

Has your child had all their vaccination shots? Did they have a reaction to any of them?

Is your child currently being breast fed?

Was your child breast fed as a baby? (for how long?)

How often does your child get colds?

How many courses of antibiotics has your child had? (when was last time?)

Does your child suffer from any of the following conditions?

  Diabetes            Epilepsy           Cancer           Asthma          ADD/ADHD           Migraines

  Learning difficulties          Overweight           Headaches          Behavioural problems

Does your child have any problems sleeping? (If yes, please provide duration.)

What time does your child go to sleep?

Is your child scared of the dark?

Does your child wake at a certain time during the night? (explain why, ie. says they are cold, or hungry or scared)

Please fill in the following diet diary in as much detail as possible - including, portion size, time of meal & drinks

Breakfast:

Snacks:

Lunch:

Snacks:

Dinner:

Supper:

Is your child vegetarian or vegan?

Please list any other foods your child eats regularly:

How much water does your child drink daily?

How many juices does your child have daily? (include type, added sugar, fresh, bottled)

How many soft drinks does your child have daily? (what type?)

Does your child have problems eating any particular foods? (please explain)

Are there any foods which they really dislike?

Do they have a large or small appetite

  Small            Large

How many pieces of fruit do they eat a day?

Do they eat vegetables daily? (please list)

Do you add salt to your childs food? (how much?)

Is your child

  Coeliac (gluten intolerant)          Lactose intolerant

Do they experience excessive bloating, flatulence or burping? (after which foods in particular?)

Does your child complain of stomach aches? (after eating any foods in particular? how often and how long has this been happening?)

Do they feel nauseous or vomit (after any food in particular)?

Does your child ever complain about any pain when having bowel movements?

  Yes          No    

Does your child suffer from constipation?

  Yes          No     

  explain:

Does your child suffer from diarrhoea?

  Yes         No

  explain:

How many bowel movements do they have a day?

  1         2         3         4        5+

Is your childs stool consistency

  Loose        Hard        Watery         Contain undigested particles of food         Frothy

Is their stool colour

  Light clay        Dark brown       Yellow       Black

Does your child suffer from any of the following conditions?

  Ulcers          Cold sores        Bleeding gums        Dental problems

  explain:

Is your child teething at the moment? If so, are they having any problems?

Does your child grind their teeth?

  Yes         No

Does your child have a coating on their tongue?

  Yes         No

If yes, what colour is this coating?

Does your child suffer from any problems with their ears?

  Ear infections        Glue ear        Hearing problems        Other

  explain:

Does your child suffer from any of the following? (What makes symptoms better or worse?)

  Hay fever          Sinusitis

  explain:

Does your child get frequent runny or congested/blocked nose? (what colour is discharge?)

Does your child suffer from nose bleeds? (If so, how often & when was last one?)

Does your child suffer from any of the following?

  Poor eyesight        Conjunctivitis        Itchy eyes        Other

  explain:

Does your child suffer from any breathing problems? (please give details)

Does your child suffer from urinary tract infections? (how often, explain symptoms & treatment)

Does your child wet the bed? (how often, when did this start?)

Does your child suffer from any of the following? (please explain duration, treatments, what makes it better or worse?)

  Eczema              Psoriasis              Tinea              Flaky scalp        

  Warts                 Dermatitis             Hives             Itchy skin              Other

Does your child get nappy rash?

  Yes         No

Explain your childs usual temperament  ie. calm, aggressive, quiet, happy

What situations or foods trigger emotional reactions in your child?

Does your child have any fears or phobias? (ie, heights, spiders, the dark?)

Is your child anxious? (please explain when)

Please indicate if your child does any of the following:

  Regular temper tantrums       Cries frequently           violent/fights/kicks/screams     Short attention span

  Argumentative                     Sad / depressed           Hyperactive                            Misbehaves at school

How is your child performing at school?

Is your child social? Do they have lots of friends or prefer to play alone?

Please state mothers health during pregnancy (ie, did she suffer from anaemia, toxaemia, gestational diabetes or hypertension)?

How was the birth, was there any birth trauma to your child?

Has your child had?

  Chicken pox         Whooping cough       Mumps         Measles       

  Rubella (german measles)       Glandular fever

Does your child suffer from any recurring infections?

  Colds & flu               Tonsillitis                Ear infections            Bronchitis

  Stomach aches       Nose bleeds         Headaches

  Other   

Please list any of your childs other health events, including viruses, injuries, hospitalisations & operations in the time provided:

0 - 1 years

1 - 2 years

2 - 3 years

3 - 4 years

4 - 5 years

5 - 10 years

10+ years