Your Name*

First Last

Your Child's Name*

First Last

Email*

Enter Email Confirm Email

Date of Birth*

Address*

Street Address Address Line 2 Suburb ZIP / Postal Code Country

Mobile*

Home Phone

Work Phone

Main reason for your visit*

Where did you hear about us?

Google/Internet Search
Event/Advertising
GP/Healthcare Provider
Family/Friend
Other

Please Specify

Medical History

Has your child ever had any medical exam tests or x-rays?*

Yes
No

Please Specify:

Has he/she ever had any surgical operations?*

Yes
No

Please Specify:

Is he/she currently undergoing medical treatment?*

Yes
No

Please Specify:

Is he/she allergic to any medicines, foods or environmental substances?*

Yes
No

Please Specify:

Is your child currently taking any prescribed medication?*

Yes
No

Please Specify

Name of Product	Dosage (Per Day)	Start Date

Is your child currently taking any natural supplements?*

Yes
No

Please Specify

Brand	Name of Product	Dosage (Per Day)	Start Date

Vaccinations

Has the child ever been vaccinated?*

Yes
No

Were they fully or partially vaccinated?*

Full
Partial

Has he/she experienced any adverse reactions to vaccines?*

Yes
No

Home Environment

When was the house built?

Do you own any pets?*

Yes
No

Is the house carpeted?*

Yes
No

Does your home get damp and mouldy?*

Yes
No

For Mum

General

What is your occupation?

How old were you when you had your child?

Please enter a number from 0 to 100.

Do you have other children?

Yes
No

How many?

Have you had a miscarriage in the past?

Yes
No

Pregnancy

Did you consume any alcohol, cigarettes, caffeine and/or recreational drugs during pregnancy?

Yes
No

Please Specify:

Did you consume any medications or nutritional supplements during pregnancy?

Yes
No

Please Specify:

Were you under high amounts of stress during pregnancy?

Yes
No

Delivery

Please Select:

Natural Birth
Breech
Caesarean
Induced
Premature
Overdue
Forceps
Vacuum extraction
Other

Please Specify

Post-Natal

Is/was your child breast fed?

Yes
No

Are you or were you consuming any alcohol, cigarettes, caffeine and/or recreational drugs?

Yes
No

Has there been any major stress in your child's life?

Yes
No

Has your child ever suffered any of the following?

Please Enter any other conditions your child has/has had in the past.

Is there a family history of any conditions?*

Yes
No

Mother*

Mothers Father*

Mothers Mother*

Father*

Fathers Father*

Fathers Mother*

Siblings:*

Other:

Dental & Oral Health

Has your child ever had dental or oral health issues?*

Yes
No

Please Specify:

Does he/she grind/clench their teeth?*

Yes
No

Stools

How often does your child pass stool?*

times per*

Does he/she have diarrhoea often?*

Yes
No

Do certain foods affect his/her bowel motions?*

Yes
No

Does he/she get anal itch?*

Yes
No

Does he/she get rectal bleeding?*

Yes
No

What colour is your Childs stool normally?*

Brown/Light Brown
Light Yellow
Green
White/Clay
Black

Urine

Does he/she experience difficulty urinating?*

Yes
No

Do he/she experience problems with frequency/urgency of urinating?*

Yes
No

What colour is your Childs urine normally?*

Clear/Pale Yellow
Yellow
Dark Yellow
Pink/Red
Brown/Orange
Foaming/Fizzing

Diet

How much water does your Child drink daily?*

*

Other than water what beverages does he/she consume each day?

How would you rate his/her appetite?

Low
Good
Excessive

Please list any foods that your child may have intolerance to:

Please list any foods that are being actively avoided:

Please list any foods he/she craves:

What type of foods do you typically eat from day to day?

What foods does he/she eat for Breakfast?*

Weekday	Weekend

What foods does he/she eat for Lunch?*

Weekday	Weekend

What foods does he/she eat for Dinner?*

Weekday	Weekend

What foods does he/she eat for Snacks?

Weekday	Weekend

Thank you for your time.

Please note that all information provided will be strictly confidential and will not be disclosed to anyone without your permission.

CAPTCHA

Health Questionnaire - Kids

Medical History

Vaccinations

Home Environment

For Mum

General

Pregnancy

Delivery

Post-Natal

Dental & Oral Health

Stools

Urine

Diet

What type of foods do you typically eat from day to day?

Thank you for your time.

Clinic Contacts