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Child's Current Age *
Primary Parent/Guardian's email address *
Primary Parent/Guardian's phone *
Secondary Parent/Guardian's email address *
Secondary Parent/Guardian's phone
Is there anything regarding custody, parents, guardians or home life that I should be aware of? *
Please list all herbs, vitamins and supplements the child is currently using. If none, please write none. *
Please list all medications the child is currently using. If none, please write none. *
Please list all medical conditions the child is currently being treated for. If none, please write none. *
Please list any allergies that you are aware of, diagnosed or suspected? If none, please write none. *
Please list any major accidents, broken bones, concussions, whiplash, sport injuries, etc.
and medical you
Please list any surgeries (with approximate age)
Please list any major dental work done (braces, teeth removal, root canals, fillings, etc)
Please list any treatments or other therapies the child is currently using *
Please list any treatments or other therapies the child has used in the past and for what. If none, please write none. *
Born pre-mature?
Was the birth uncomplicated?
How has the health of the child been up til now?
Where there any significant traumas/episodes, with approximate age (divorce, loss of a family member, abuse, other traumatic events, etc)
How many hours per day does the child look at a screen? (computers, phone, television, etc)
What type of physical activity does the child engage in and for how long? (walking, sports, weight/strength training, running, other physical activities, etc)
Please explain any dietary restrictions (religious, vegetarian, vegan, dairy free, gluten free, low histamine, etc) or specialized diets (GAPS, FODMAPS, keto, bariatric, etc)
What areas of life do you believe are affecting the child's stress levels? *
Any addictions? (Food, gaming, gambling, phone, sex, drugs, social media, etc)
Any recent traumas/episodes?
Is there anything else you feel would be important to share? *
What areas, problems or goals would like help with now? List in order of importance. *
By typing your first and last name in the box below, you agree that you have read, understood and agree to the above statements. (If under the age of 18 years old, the name typed will be that of a parent or guardian.) *