Kids In clinic Booking – Initial Consultation Please complete the below form. Full Name Email Address Phone Number Date of Birth Age Gender GenderYesNo Postal Address Suburb State/Postcode PARENT INFORMATION Parents Full Name Occupation MAIN ISSUES Onset - Location - Duration - Frequency (Better/Worse) Fever - Onset - Duration Pain - Onset - Location - Sensation ((Sharp/dull/throbbing/numb/radiation) Have you got any known allergies? Have you got any known allergies?YESNO Duration Temperature Vomiting VomitingYESNO Duration Diarrhoea DiarrhoeaYESNO Duration FAMILY HISTORY Mother Father Siblings Maternal Grandparents Paternal Grandparents Other Relations BIRTH HISTORY Significant events during pregnancy (both physical & emotional) Signification events during delivery (forceps/caesarean/complications) Congenital Disorders Current treatment for disorders MEDICAL DETAILS Immunisation ImmunisationYESNO Last Immunisation Date Symptoms from Immunisation Medical History/Operations Medications - Dosage/Duration What is your Vaccination history from birth to current? Allergies and Allergy Symptoms DIET Usual Daily Diet (Appetite) Usual Daily Diet (Appetite)deficientnormalexcessive Breakfast Lunch Dinner Snacks Water Juice Soft Drinks Gastrointestinal System Gastrointestinal System nausea vomiting flatulence colic sabdominal pain dyspepsia reflux pica Bowel: (nappy/Diaper) Use Bowel: (nappy/Diaper) UseYESNO Bowel: Potty Training Bowel: Potty TrainingYESNO Potty Training Duration Bowel: Frequency Bowel: Diarrhoea/Constipation Bowel: Diarrhoea/Constipation Bowel: Colour Bowel: Consistency Bowel: Texture (food) Bowel: Stool (float/sink) Bowel: Pain Bowel: Bleeding URINARY SYSTEM (dysuria, nocturia, enuresis) Frequency Quantity Pain (onset, location, type, duration, < >, radiation) Colour Odor Passing Passing involuntary difficulty dribbling Infections Others Pain Scale Pain Scale 😃 GREAT 🙂 GOOD 😐 OK 😏 A LITTLE PAIN 😟 IT HURTS 😩 LOTS OF PAIN DEVELOPMENT MILESTONES (dysuria, nocturia, enuresis) Crawling Walking Talking Learning Difficulties Social Skills (siblings, playmates, preschool, class interactions) SLEEP AND ENERGY Energy Level Sleep Patterns Sleep Patterns wake frequently sudden sleep nightmares sleep walk NUTRITION Still Breastfeeding Still BreastfeedingYESNO Duration Formula Milk Formula MilkYESNO Duration Cow's Milk Cow's MilkYESNO Duration First Tooth Since Current Teeth Count Dental Caries Started on Solid Foods Started on Solid FoodsYESNO Duration Food Intolerances Recent New Foods Disclaimer: Each individuals health condition will vary and even the gentlest therapies may cause complications with certain physiological conditions. Some therapies will be used with caution in certain disease states eg: liver, kidney, heart disease or diabetes. Please note: it is very important to disclose all information immediately to your Naturopath of any disease that you are suffering from including current and change in medications prescribed and over the counter that you are taking. If pregnant, breastfeeding or suspect pregnancy advise Naturopath immediately. Statement of Acknowledgement Please tick all below boxes as acknowledgement. Please tick all below boxes as acknowledgement. You understand Naturopathic Doctors ND are not Medical Doctors; we use non- invasive, natural methods in assessing you for treatment of body dysfunctions. That you understand the treatment and or referral to other health practitioners is based upon the assessment of your health through your personal history, tests and other necessary methods of evaluation. You understand the complete responsibility for your health care is your own and I will be supportive of this. I do reserve the right to discontinue my services where your expectations and what I provide are not in agreement. I understand that a record will be kept of health services provided to me. These records will be kept in confidence and not released to others unless you give your consent or the law requires it. I understand my Naturopath will answer questions to the best of her ability and understand that results are not guaranteed. I do not expect my Naturopath to be able to anticipate all complications and risks for example allergic reactions to herbs and supplements. I will rely on my Naturopath to express judgment during the course of the treatment plan which they feel at the time is in my best interests based on the health facts then known. I understand this consent form covers my whole course of treatment under my Naturopath practitioner. I understand I am free to withdraw my consent and discontinue participation in treatment at anytime. By signing name below and clicking submit I agree that I have read completely and understood the above information. SUBMIT
