Nutrition Form -

Nutrition Form

Nutritional Form Magdalena Kent

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Child's first name

Child's surname

Gender

Male

Female

Address

Parent/carer telephone number

Parent/carer email address

Child's date of birth

Child's 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)

Who lives at home with child

Please detail if there are any pets at home

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?

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

Mumps

Rubella

Scarletina

Herpes

Other

None

Please check all that apply now or previously applied.

Poor co-ordination

Recurrent chest infections

Hates bright lights

Chronic stuffy nose

Sensitivity to noise

Threadworms

Phobias

Night terrors

Constant runny nose

Travel sickness

None

Child's personality/behaviour

Nervous

Irritable

Contented

Excitable

Easily distracted

Restless

Alert

Impulsive

Messy

Lazy/lethargic

Nail biter

Clumsy

Sleepy

Poor eyesight

Restlessness

Acne

Moody

Insomnia

Mouth ulcers

Tendency to allergies

Diarrhoea

Short attention span

Eye pains / discomfort

Lack energy

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

Learning difficulties

Swollen ankles or hands

Poor sleep

Muscle pains / cramps

Sweaty

Excessive tiredness

Thin hair / hair loss

Fits or convulsions

Fatigue

Constipation

Irritability

Muscle weakness

Dry skin

PMT

Bed wetting

Frequent infections

Slow growth

Pale skin

Easily bruising

Slow wound healing

Nausea

Loss of appetite

Itchy skins

Acne

Poor concentration

Tendency to allergies

Red pimples eg upper arms

White spots on nails

Stomach pains

Moody

Poor appetite

Frequent infections

Sore knees

Drowsiness

Diabetes

Frequenct infections

Poor concentration

Addicted to sweet foods

Needs frequent meals

Does your child suffer frequent colds, coughs, infections?

Yes

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 chew food well?

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

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 been hospitalised since birth?

Yes

Has your child received 4 or more courses of antibiotic drugs during the past year?

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 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

Would you describe your child as ‘hyperactive?'

Yes

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

Yes

Is your child unusually tired or moody or depressed?

Yes

Is your child a bottom scratcher?

Yes

Does your child crave sweet foods?

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, casein 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 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)

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 understand that all notes and reports will be stored by my child's individual Therapist

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 initial consultation and assessment services 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

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