Consultation Questionnaire

Name *

First

Last

Name of Child Coming as Patient

First

Last

Address

Email *

Date of Birth *

Please list any medication currently being taken? Names and dosage

Please list any supplements or microbiotics currently being taken? Names and dosage

Please list any illnesses/operations/injuries or major hospitalizations.

Rate Sleep Patterns on the Slider

Selected Value: 2

0 Insomnia, 1 Constantly waking, 2 Occasionally restless, 3 Rarely waking, 4 Refreshing sleep

Rate Fitness Levels on the Slider

Selected Value: 2

0 Not at all 1 Somewhat fit, 2 Occasionally active 3 Average fit 4 High fitness

Rate Health Levels on the Slider

Selected Value: 2

0 Least Contented, 1 Somewhat, 2 Occasionally Contented 3 Average, 4 High Contentment

Rate Energy Levels on the Slider

Selected Value: 2

0 Least Contented, 1 Somewhat, 2 Occasionally Contented 3 Average, 4 High Contentment

Rate Pain or Anxiety Levels on the Slider

Selected Value: 2

0 Least Contented, 1 Somewhat, 2 Occasionally Content, 3 Average, 4 No Anxiety or pain

Click if affected by any/all of the following Digestive Issues.

Click if affected by any/all of the following Energy Issues.

Click if affected by any/all of the following Eye Issues.

Click if affected by any/all of the following Nose Sinus Lung Issues.

What are your reasons for the Consultation? *

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