CHILD
FIRST NAME / SURNAME
DATE AND COUNTRY OF BIRTH
WEIGHT (kg)
HEIGHT (cm)
CHILD’S GP’:
NAME
PRACTICE ADDRESS
PARENT / CARER
NAME
HOME ADDRESS
TELEPHONE
MEDICAL AND FAMILY HISTORY
►KNOWN OR SUSPECTED ALLERGIES / SENSITIVITIES (food, environmental, drug)
►MAIN REASONS FOR THIS VISIT
►CHILD’S MEDICAL HISTORY
INFECTIONS
Chicken pox, mumps, measles, rubella, encephalitis, meningitis, herpes simplex, ear infections, sore throat, frequent colds, other
OTHER CONDITIONS
Seizures, asthma, hay fever, oral thrush, athletes foot, grommets, hearing loss, dark circles under the eyes, eczema, other
VACCINATIONS
Standard programme / any vaccinations excluded and reasons / any adverse reactions to vaccination
ANTIBIOTICS
Has your child ever had antibiotics, and if so, when was their first course, what type and how many course so far?
►CHILD’S CURRENT OR FREQUENTLY TAKEN MEDICATIONS AND/OR SUPPLEMENTS Prescription, non-prescription, herbal, vitamins etc. Please, state the name, dosage, for how long has been takenand any issues / side-effects
►LAB. TESTS / INVESTIGATIONS IN THE LAST YEAR Please, send or bring the copies of the test results, if possible.
►IF CHILD IS CURRENTLY RECEIVING ANY THERAPY OR RECEIVED IN THE PAST:
NAME OF THE HEALTH CARE PROVIDER
TYPE AND DURATION OF THE THERAPY
OUTCOMES
►CHILD’S FAMILY MEDICAL HISTORY
MOTHER
FATHER
GRANDPARENTS
SIBLING/S(AGES AND HEALTH)
Are there any unexplained symptoms in your immediate family (please describe)?
HISTORY, SYMPTOMS AND HABITS / YES tick / PROVIDE DETAILSPRE-NATAL / BIRTH
Birth: natural, induced, forceps, CS...
Post-Natal Depression
Stressed during pregnancy
Dental work during pregnancy
Normal gestation, term (40 weeks)
Renovations to house during pregnancy
Apgar score
Was there any jaundice?
Was there any oxygen deficit?
Did baby need special care? Reasons?
When formula milk was introduced?
Was baby breastfed? Details
Was baby’s bedroom renovated?
ENVIRONMENT
House - Damp/mould/condensation?
Did baby sleep on it’s own mattress?
Does anyone smoke at home?
Living close to pylons/mobile phone mast/flight path?
Do you have wi-fi on in your home?
Living close to sprayed farmland?
Occupation/s of mother
Occupation/s of Father
Are there pets at home?
Does your child go to school?
Has your child adjusted to school well?
Living close to a busy road/train track?
DIGESTIVE AND URINARY SYSTEMS
Daily Bowel Movement
Constipation
Diarrhoea
Bad Breath
Itchy Bottom, rash, irritation
Bloating
Excessive Flatulence
Undigested foods in Stools
Mucus in Stools
Loose Stools
Colour of Stool?
Pale Stools
Offensive Stools
Large Bulky Stools
Pain when passing stools
Is your child toilet trained?
Does your child wet the bed?
Increased frequency of urinating?
CHILD’S EATING HABITS
Does your child overeat?
Does your child regurgitate/reflux?
Does your child have pica?
Child having problem with textures?
Using plastic bottles or plates?
Does your child crave any foods, which ones?
Daily amount and type of fruits
Daily amount and type of vegetables
Daily amount and type of fluid taken
Do you use filtered water? What type?
Amount and type of sweet foods eaten (per week)
Do you buy/use organic foods?
Where do you shop for food?
How often do you cook meals at home?
SPECIAL DIETS / EFFECTS AND DURATION ON THE DIET
Low sugar diet
Gluten free
Casein free
Specific Carbohydrate Diet (SCD)
Gut and Psychology Syndrome (GAPS)
Body ecology Diet
Feingold Diet
FODMAPS Diet
ENERGY, SLEEP, SPEECH
Is your child hyperactive?
When your child wakes up are they: Tired: Hyperactive, Neither
Does your child speak?
Does your child tire easily?
Best time of day for your child? Morning, Midday, Evening, Before or After Food?
Does your child have Obsessions?
Do the obsessions vary?
Does your child get fevers often?
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