Please tick and complete where appropriate. Leave blank if information is not relevant, not known or you would prefer not to answer the question.
Your child's needs
What are the main health issues you would like us to focus on?
What would you like to achieve from your child's Health Optimising support (eg more energy, sleep better, more emotionally balanced )
Your child's medical history
Does your child have now or have they ever experienced any of the following? Or do you have a family history of them?
Does your child have any of these physical characteristics?
On testing has your child ever had the following diagnosed?
Have your child had, or do they currently have, any of the following infections?
Have your child had any of these removed?
Your child's toxic panel
Which of the following vaccinations has your child had?
Has your child ever had any travel vaccinations?
Mother's pregnancy/ birth
Your child's feeding, digestion and nutrition
What does your child's typical day’s diet look like?
Please indicate how these statements describe your child;
How many caffeinated drinks does your child have daily?Please indicate number of cups per day in the boxes
Does your child currently take any nutritional supplementation?
Your child's energy and sleep
Your child's cycle/periods - please answer these questions from your child's perspective if relevant
Does your child suffer from any of these linked to her cycle?
Your child's mind, mood and stress - please answer these questions from your child's perspective
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