Name of the child
*
First Name
Last Name
Email (to contact parent or carer)
*
Please confirm email
*
Phone number (to contact parent or carer)
*
Child's date of birth
*
MM
DD
YYYY
Sex
*
Please select an option
Female
Male
Prefer not to say
Weight
Height
Blood group (if known)
Colour of the eyes
Reason(s) for arranging a consultation
The more details the better!
Have you and your child ever met with a naturopath before?
What do you wish to achieve from the session?
What is the child's family environment?
Does the child has siblings?
Does the child receive any sort of daycare?
School
Birth
Breastfeeding
Sleep (night)
Sleep (nap times)
Health
Vitamins & supplements
Childhood illnesses
Allergies
Vaccinations
How would you describe the child's level of energy?
Very good
Good
Average
Low
Activities
Quiet times
Social life & social skills
Emotions
Personality & behaviour
Health visitor development assessment
Potty training
Medical family background
Please describe the child's family background (genetic inheritance, heart attacks, cancers, diabetes, osteoarthritis, mental illnesses, etc.).
Migraines / headaches
Catarrh (mucus / inflammation of nose and throat)
Hay fever
Sneezing
Eyes inflammation
Mouth ulcers
How does the child's skin feel like?
Please select as many options as you like.
Smooth
Soft
Dry
Rough
Skin conditions
Herpes, acne, psoriasis, eczema…
Nails
Please select an option
Hard
Soft
Brittle / easily break
Asthma
Muscles / bones
Pain, fractures...
Digestion
Weight
Steady, obesity / thinness, eating patterns, eating disorders, sudden weight loss / gain...
Chronic issue(s)
Rhino, bronchitis, sinusitis, ear infection, sore throat...
Teeth
Other
Anything else that hasn't been covered above and that is worth mentioning.
Food allergies
Food intolerances
Special diet
Vegetarian, vegan, etc...
Please describe the child's usual type of breakfast
Please describe the child's usual type of lunch
Please describe the child's usual type of dinner
What about snacks?
Appetite
What is the child's favourite taste?
Sweet
Savoury
Does the child drink water throughout the day?
What are the child's favourite foods?
Do you use organic products when cooking fo the child?
Every day
Often
Sometimes
Never
What type of sugar do you normally use when cooking fo the child?
Please select as many options as you like.
Honey
Agave / maple syrup
Brown sugar
White (refined) sugar
Natural sweetener (Stevia)
Other type of sweetener (Canderel type)
What type of bread, rice and flour do you normally use when cooking fo the child?
Please select as many options as you like.
Refined (white)
Semi-refined
Wholemeal
What type of oil do you normally use when cooking fo the child?
Please select as many options as you like.
Organic
First cold press
Olive
Rapeseed
Sunflower
Mixed oils
What do you usually use when cooking fo the child?
Please select as many options as you like.
Fresh products
Frozen products
Industrial products
Tinned food
Does the child consume any of the following products?
Please select as many options as you like.
Butter
Margarine
Chocolate spread
Jam
Marmite
Tea / herbal tea
Never
Occasionally
Once or twice a day
3 times a day or more
Fruit juice / soda
Never
Occasionally
Once or twice a day
3 times a day or more
Milk / yogurt / other types of dairy desserts
Never
Occasionally
Once or twice a day
3 times a day or more
Cheese
Never
Occasionally
Once a day
Twice a day or more
Fish
Never
Occasionally
Once or twice a week
3 to 6 times a week
Every day
White meat
Chicken, pork...
Never
Occasionally
Once or twice a week
3 to 6 times a week
Every day one meal
Every day both meals
Red meat
Never
Occasionally
Once or twice a week
3 to 6 times a week
Every day one meal
Every day both meals
Cured meat
Never
Occasionally
Once or twice a week
3 to 6 times a week
Every day one meal
Every day both meals
Fresh / frozen vegetables
Never
Occasionally
Once or twice a week
3 to 6 times a week
Every day one meal
Every day both meals
Fresh fruit
Never
Occasionally
Once or twice a week
3 to 6 times a week
Every day one meal
Every day both meals
Starchy foods
Bread, rice, pasta, potatoes...
Never
Occasionally
Once or twice a week
3 to 6 times a week
Every day one meal
Every day both meals
Legumes
Chickpeas, beans, lentils...
Never
Occasionally
Once or twice a week
3 to 6 times a week
Every day one meal
Every day both meals
Pastries / cakes / desserts
EXCEPT FRUIT / FRUIT PURÉE or COMPOTE
Never
Occasionally
Once or twice a week
3 to 6 times a week
Every day one meal
Every day both meals
Is there anything else that hasn't been covered and that you would like to add?