Pre-Consultation Questionnaire Babies and Children If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Child's Full Name * Parent's Names * Address * Date of Birth * How did you hear about Dina? * What is the reason for your child having this naturopathic consultation? Please list symptoms or conditions you would like improved or treated. * List any conventional medications, vitamin or mineral supplements or anything else your child is currently taking: Is your child allergic to anything? * Is your child currently seeing any other health practitioners? * Has your child had any medical tests or investigations recently? If so, please include reasons for tests and bring results along to consultation if available. * Has your child been immunised? * I feel my child has not been well since...(eg a particular event, travel, illness etc) Family History - Please list any major diseases that are present or have been present in your child's immediate family - parents/grandparents/siblings (eg cancer, diabetes, heart disease): * Is/was your child breastfed or formula fed? (If formula fed, please state name of formula used) * How many times a year does your child get a cold or flu? * How many courses of antibiotics has your child had? When was the last course taken? * What does your child's diet look like on an average day? Please list breakfast, lunch, dinner, snacks and fluid intake * Digestive Health - Does your child currently experience: Nausea or VomitingRecurrent stomach achesDiarrhoeaConstipationColicFlatulence and BloatingReflux Bowel Movements - How often does your child have a bowel movement? * Once a daySeveral times a dayOnce every 2-3 daysOnce a week Bowels - Are your child's stools normally: (Not the nicest question to ask but it's important) * YellowLight brownMedium brownDark brownGreenWell formedLoose/not well formedWith blood in them Respiratory System - Does your child ever experience: HeadachesDizzinessSwollen glandsHayfeverSinus issuesNosebleedsCoughsShortness of breathAsthmaEar infections Urinary System - Does your child ever experience: Pain or burning on urination (or does your child complain of this)Bed wettingRecurrent Urinary Tract InfectionsThrush Sleep and Energy levels - Does your child: Have any problems getting to sleep or staying asleep?Complain of nightmares?Have a fear of the dark?Have energy slumps during the day?Feel tired and lethargic after eating? Musculoskeletal System - Does your child ever experience: Aching musclesMuscle spasms Skin Health - Does your child suffer from any skin issues such as eczema, dermatitis, psoriasis, warts, itchy skin, nappy rash or something else? Please give details * Emotional Health - Explain your child's usual temperament: * Past Health History - Describe mother's health during her pregnancy and labour/birth of child: * Is there anything else that you can think of that might affect your child's health?