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  • Services
    • Book a Consult
    • Services & prices
  • Store
  • Blog
  • About
    • Testimonials
  • Contact

Parental Questionnaire

Please fill in this questionnaire after you have booked a consultation for a child under 16 years of age. 

    PERSONAL DETAILS

    MEDICAL HISTORY

    e.g. allergy, asthma, urticaria, auto-immune, psoriasis; medications; fish/ type consumption; vaccinations; environmental/ occupational exposure

    Pregnancy & Birth

    e.g. allergy, asthma, auto-immune, psoriasis; medications/ immunizations; Rhogam; oral contraceptive; fish/ type consumption; environmental/ occupational exposure.

    CHILD

    Any and all antibiotics taken, please include the age the child was when having them. Detail any adverse reactions.
    eg. for grommets
    Describe first signs or concerns Outline development or observations
    Include adverse reactions or changes in behaviour.
    e.g. allergy, asthma, urticaria, auto-immune, psoriasis; medications; fish/ type consumption; vaccinations; environmental/ occupational exposure
    eg. formula, soy, cows milk
    PICA? (eating non edible things) list typical foods eaten
Submit
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