Nutrition Form Children -

Nutritional Form for Children & Families

Nutritional Child & Families - KENT

Updates

Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10

Child's first name

Child's surname

Address

Telephone number

Parent/Carer work number

Mobile number

Email address

Child's age

Date of birth

Ethnic origin

Child's height

Child's weight

Main reason for visit

Mother's name

Are you the birth mother?

Age

Any health problems

Father's name

Are you the genetic father?

Age

Any health problems

Any brothers or sisters? If yes, please include their age, gender and if they have any health problems

Are there any particular illnesses and/or allergies in the family (eg heart disease, diabetes, asthma, eczema, hay fever, food allergies etc) - state which

Who lives at home with child

Does your child have access visits to a parent?

Is your child part of a step-family?

Please detail if there are any pets at home

Does your child attend mainstream school or special school?

Does your child have home tutoring?

Has your child ever received a statement of educational needs?

Does your child receive extra educational help at school (If yes, please expand)

GP name

GP address

GP telephone number

Is your GP aware you are consulting a nutritional therapist?

Are you happy for your GP to be kept informed?

Any other health professionals involved in your child’s care

Did you receive any fertility treatment prior to conceiving or conceive this child naturally?

Did you have any complications / treatments in pregnancy?

Did you suffer any illnesses in the pregnancy, eg viruses, operations etc

Any additional information about this pregnancy

Did you exclude any foods

Did you ‘go off’ any foods

Did you crave any foods or non-foods?

Was this your first labour

Duration of pregnancy (normal gestation is 40 weeks)

Length of labour

Did you have a spontaneous or induced labour?

Type of birth

Place of birth

Hospital

Home

Birth weight

Did your child require special care? If yes, why and for how long?

Has your child suffered infections requiring antibiotics?

Yes

If yes, please give age, illness, treatment

What tests has your child had by GP, specialist, other?

Does / has your child take/taken any other prescribed medications?

Yes

If yes, please give age, illness, treatment

Has your child received a medical diagnosis of any condition?

Yes

If yes, please expand (eg asthma, coeliac disease, anaemia)

Does your child take over the counter medications?

Yes

If yes, which and for what eg Calpol or anti-histamines

Have you sought ‘alternative’ health care advice for your child eg homeopath, cranial osteopath?

Yes

Has your child ever been referred to a specialist?

Yes

If yes, please give age, reason, type of specialist

Any other medical information?

Has your child’s growth pattern been ‘normal’ eg height, weight, growth centile

Yes

If no, please detail

Has your GP, Health Visitor or any other medical practitioner ever expressed concern regarding your child’s development?

Yes

If yes, please expand eg speech, learning, walking, hearing, vision

Has your child received the recommended standard immunisations including boosters, meningitis and BCG?

Yes

If no, please detail those given and those excluded and why

Has your child ever had an adverse reaction to any vaccine?

Yes

If yes, please expand

Has your child had any of these infectious diseases?

Whooping cough

Measles

Chicken pox

Please check all that apply now or previously applied.

ear ache

poor co-ordination

recurrent chest infections

hates bright lights

chronic stuffy nose

aggression

mood swings

sensitivity to noise

threadworms

phobias

night terrors

shows no fear

disturbed sleep

constant runny nose

travel sickness

Specific disorders

Asthma

ADD/ADHD

Autism/Autism Spectrum Disorder

Hayfever

Heart Disease

Cystic Fibrosis

Food Allergies

Epilepsy

Diabetes

Scabies

Arthritis/Still’s Disease

Haemophilia

Dyslexia

Crohn’s Disease

Cancer

Dyspraxia

Thalassaemia

AIDS

Cerebral Palsy

Sickle Cell Anaemia

Other

Child's personality/behaviour

irritable

excitable

Poor eyesight

Restlessness

Acne

Moody

Insomnia

Mouth ulcers

Tendency to allergies

Tooth decay

Diarrhoea

Short attention span

Joint pains

Eye pains / discomfort

Lack energy

Brittle nails

Thrush

Headaches / migraines

Nervousness

Chest or urinary infections

Anxiety or tension

Bed wetting

Dry, flaky skin

Nausea or vomiting

Frequent urination

Frequent colds/infections

Insomnia

Nose bleeds

Asthma

Near sightedness

Learning difficulties

Swollen ankles or hands

Poor sleep

Muscle pains / cramps

Anxiety

Sweaty

Nervous or anxious

Sore joints / bone pains

Hyperactivity

Excessive tiredness

Pins and needles in hands

Fits or convulsions

Fatigue

Constipation

Irritability

Muscle weakness

Dry skin

PMT

Bed wetting

Slow growth

Pale skin

Lack of energy / lethargy

Slow wound healing

Menstrual problems

Weak muscles

Loss of appetite

Fatigue on exertion

Red pimples eg upper arms

Easy bruising

Breathlessness

White spots on nails

Irritability

Stomach pains

Bleeding gums

Sore lips

Moody

Poor appetite

Frequent infections

Sore knees

Fits or convulsions

Learning difficulties

Drowsiness

Diabetes

Muscle pains

Slow growth learning difficulties

Excessive thirst

Tendency to allergies

Addicted to sweet foods

Needs frequent meals

Skin problems

**For girls only** At what age did your daughter’s periods start? (Leave blank if not applicable)

**For girls only** Are the periods regular, heavy or painful? (Leave blank if not applicable)

**For girls only** Does your daughter take the contraceptive pill for period problems, acne or contraception? (Leave blank if not applicable)

**For girls only** Does your daughter ever have a vaginal discharge that itches? (Leave blank if not applicable)

**For girls only** Does your daughter have any irregular bleeding between periods? (Leave blank if not applicable)

How much time per day does your child watch TV?

How much time per day does your child use a computer (including school and home)?

What sport does your child play?

Any active hobbies/clubs (eg dancing)

Does he / she walk / cycle to and from school?

Does your child suffer frequent colds, coughs, infections?

Yes

Does your child have eczema, asthma, hayfever, arthritis, migraine. If yes, which?

Does your child suffer from food sensitivity?

Yes

Have you noticed any adverse reactions in your child after eating certain foods? If so, state which foods and what reactions

Does your child live in a city or by a busy road?

Yes

Does your child usually drink filtered or bottled water?

Yes

Does your child eat mainly non-organic foods?

Yes

Is the main home near to: pylons, mobile phone mast, factory, petrol station, agricultural land, flight path. If yes, which?

Does your child have a TV or computer in their bedroom?

Yes

Does your child have a mobile phone which is used regularly?

Yes

Does your child chew food well?

Yes

Does your child suffer from bad breath?

Yes

Does your child suffer stomach upsets?

Yes

Does your child suffer with an itchy bottom?

Yes

Does your child have a daily bowel movement?

Yes

Does your child suffer from diarrhoea or constipation?

Yes

Does your child suffer from bloating/excessive wind?

Yes

During the 2 years prior to your child’s birth were you bothered by recurrent vaginitis, PMT, fatigue headache, depression, digestive disorders or ‘feeling generally unwell?

Did / does your child suffer from thrush?

Yes

As an infant did your child have frequent nappy rashes or have any recent anal redness?

Yes

During infancy, was your child colicky and irritable lasting over three months?

Yes

Was your baby a headbanger?

Yes

Has your child attended a day care centre in first 3 years of life?

Yes

Has your child been hospitalised since birth?

Yes

Has your child swum in freshwater lakes or streams?

Yes

Has your child been on ‘exotic’ holidays such as the Carribean or Far East?

Yes

Has your child received 4 or more courses of antibiotic drugs during the past year or received continuous preventative courses of anti-biotic drugs?

Yes

Has your child received 8 or more courses of ‘broad spectrum’ antibiotics during the past 3 years eg for chest or urinary infections?

Yes

Has your child received steroids eg for eczema or asthma

Yes

Has your child been bothered by persistent or recurrent digestive problems, including constipation, diarrhoea, bloating, foul smelling stools or excessive wind?

Yes

Has your child experienced recurrent or persistent athlete’s foot or chronic fungus infections of skin or nails?

Yes

Has your child been bothered by recurrent hives, eczema or other skin problems?

Yes

Has your child experienced recurrent ear problems or had tubes inserted in his / her ears?

Yes

Has your child been bothered by persistent nasal congestion, cough and/or wheezing?

Yes

Has your child been labelled ‘hyperactive?

Yes

Does your child have learning problems, even though his/her early developmental history was normal?

Yes

Does your child have a short attention span?

Yes

Is your child persistently irritable, unhappy and hard to please?

Yes

Is your child unusually tired or moody or depressed?

Yes

Does / has your child suffered recurrent headaches, abdominal pain, or muscle aches?

Yes

Is your child a bedwetter?

Yes

Is he/she a bottom scratcher?

Yes

Does your child crave sweet foods?

Yes

Does your child drink tap water rather than bottled or filtered water?

Yes

Do you have a puppy or kitten at home?

Yes

Do you feel that your child isn’t well, yet diagnostic tests have not revealed the cause?

Yes

Did you breast feed at all?

Yes

For how long?

Did you bottle feed at all?

Yes

At what age?

Which formula?

Which if any special formula were required eg soya, cassein free?

How old was your baby when you started weaning onto solids?

Did you offer ready made baby foods?

Yes

At what age?

Would you describe your child’s appetite as:

Is your child a ‘fussy’ eater?

Yes

Is your child currently following a specific dietary regime (such as gluten free)?

Are there any foods which your child craves?

Are there any foods which your child dislikes intensely?

Do you go out of your way to avoid giving foods containing preservatives and additives?

Yes

Do you avoid giving foods which contain sugar?

Yes

How many cans of fizzy drinks does your child drink in a week?

How many times a week does your child have meals containing fried or fast foods (such as fish fingers or McDonalds)

How many portions of fruit and vegetables does your child have daily?

How many slices of bread or rolls does your child eat daily?

Does your child normally eat white or wholemeal rice, pasta and flour?

What nutritional supplements does your child take on a daily basis? (please include brand and dose and bring to consultation)

Does your child take a ‘lunch box’ or have school dinners?

Yes

Does your child skip meals such as breakfast?

Yes

Is your child always hungry?

Yes

Does your child normally eat white or wholemeal rice, pasta and flour?

Please tick the boxes to show whether you give consent to the following:

I agree for my child to be seen for an assessment and/or therapy by The Children's Wellness Centre Nutritional Therapy Team run by Magdalena Marvell. I understand I can withdraw my consent at any time

I agree for any relevant information about my child to be shared between relevant professionals (e.g. school, doctor, psychologist, NHS therapist etc) in confidence, in the best interest of the child’s development

I understand that audio, video or photographic records may be made as part of my child’s assessment and therapy

I agree to the use of electronic communication. All documents will be password protected and saved as a PDF

Terms and Conditions of Therapeutic Services within The Children’s Wellness Centre. By ticking the following checkbox, the client is accepting the terms and conditions below

Our Therapists will adopt a client-led approach and will offer advice, support and options for next steps, but it is the client’s responsibility to decide what is right for their child

The Therapist that you are seeing is DBS checked and holds Professional Indemnity insurance, practicing within the framework of their profession and registrations

The Therapist reserves the right not to accept a referral, terminate an assessment or not to circulate an assessment report if the referral appears to be outside their area of expertise or the client fails to comply with the terms and conditions set out in this agreement

Any information shared by the client with the Therapist and The Children's Wellness Centre is treated as confidential, unless a safeguarding concern is disclosed. Client details will not be passed onto other parties unless specifically requested e.g. forwarding reports to other professionals and schools

Payment for Occupational Therapy Assessments is required at the time of booking, in order to secure the space. Payment for weekly therapy sessions is due 48-hours prior to each session

Payment is usually made via BACS and clients will receive an email invoice once they have booked. Your assessment is confirmed on receipt of payment

If need be, payment can be made via cash or card, however due to COVID-19 and reducing social contact, our reception hours are currently limited. We can arrange a set time for you to come into the practice and pay this way, if required.

Please note we have a 48-hour cancellation policy. Late cancellations (not within 48-hours) and missed appointments, will still need to be charged in full

For any clients claiming through their health insurance, payment must be settled directly with The Children’s Wellness Centre by the client and can be reclaimed via their insurance provider, using the receipt we can provide

If the client has a complaint against the Therapist that they are seeing, they must inform The Children’s Wellness Centre, emailing jake@childrenswellnesscentre.co.uk immediately and all efforts will be made to resolve and settle any disputes, without litigation