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Home
Services
Book a Consult
Services & prices
Store
Blog
About
Testimonials
Contact
Please fill in this questionnaire after you have booked a consultation for a child under 16 years of age.
PERSONAL DETAILS
*
Indicates required field
Name of Patient
*
Email Address
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Date of Birth
*
Age
*
Mobile Phone Number
*
Mothers Name
*
Siblings - names & ages
*
MEDICAL HISTORY
Fathers Name
*
FATHER - medical history
*
e.g. allergy, asthma, urticaria, auto-immune, psoriasis; medications; fish/ type consumption; vaccinations; environmental/ occupational exposure
Illness in Paternal side of family
*
How many amalgam fillings does the clid have? when were they placed?
*
Pregnancy & Birth
Any medical procedures during pregnancy?
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Childs Place of birth
*
Difficulty of labour?
*
Other events at birth
*
MOTHER - medical history
*
e.g. allergy, asthma, auto-immune, psoriasis; medications/ immunizations; Rhogam; oral contraceptive; fish/ type consumption; environmental/ occupational exposure.
Illness in Maternal side of family
*
Any amalgam fillings placed in the mother during pregnancy or breastfeeding?
*
Any unusual event during pregnancy?
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Type of delivery?
*
Birthweight.
*
Condition of child at birth.
*
CHILD
Breastfed?
*
YES
NO
Breastfed for how how long?
*
Fevers
*
Antibiotic history and any reactions.
*
Any and all antibiotics taken, please include the age the child was when having them. Detail any adverse reactions.
Surgery
*
eg. for grommets
Seizures - age & circumstances
*
Any disorders since birth?
*
Describe first signs or concerns Outline development or observations
Allergies
*
Injuries
*
Infections
*
Vaccination History
*
Include adverse reactions or changes in behaviour.
CURRENT Health Concerns
*
Abdominal Pain
Bloating
Burping
Colic
Constipation
Diarrhea
Flatulance
Allergic Rhinitis
Asthma
Bronchitis
Chemical Sensitivities
Chest Congestions
Chronic Cough
Food Allergies
Frequent cold infections
Hay Fever
Lymph nodes enlarged
Seasonal Allergies
Athlete's Foot
Foot Cracking, Peeling
Nail Fungus
Red Ring around Anus
Ring Worm
Thrush
Vaginitis
e.g. allergy, asthma, urticaria, auto-immune, psoriasis; medications; fish/ type consumption; vaccinations; environmental/ occupational exposure
CURRENT stools
*
Bulky
Bloody
Float
Light colour
Mucus
Mushy
Strong odor
Undigested food
Formed
Soft
Liquid
PREVIOUS Health Concerns
*
Abdominal Pain
Bloating
Burping
Colic
Constipation
Diarrhea
Flatulance
Allergic Rhinitis
Asthma
Bronchitis
Chemical Sensitivities
Chest Congestions
Chronic Cough
Food Allergies
Frequent cold infections
Hay Fever
Lymph nodes enlarged
Seasonal Allergies
Athlete's Foot
Foot Cracking, Peeling
Nail Fungus
Red Ring around Anus
Ring Worm
Thrush
Vaginitis
PREVIOUS stools
*
Bulky
Bloody
Float
Light colour
Mucus
Mushy
Strong odor
Undigested food
Formed
Soft
Liquid
INFANT Eating Patterns
*
eg. formula, soy, cows milk
TODDLER Eating Patterns
*
PICA? (eating non edible things) list typical foods eaten
CURRENT Eating Pattern
*
Favourite foods/ textures
*
Most disliked foods
*
Submit