Infant or Toddler Confidential Health History (Single Child)
This Form Focuses On A Single Child
Name of Child
Name of Parent/Parents
Address
E-mail Address
Phone Number
Alternate Phone Number
Child's Age
Child's Current Height:
Child's Date of Birth and Place of Birth:
Child's Weight:
Would you like your child's weight to be different?
If so, how?
Number of Siblings and Ages
Please list your main health concerns for your child.
Other concerns or goals?
What is really working well for you and your child?
Any serious illnesses, hospitalizations/injuries?
Any food sensitivities that you are aware of?
Any unexplained symptoms (stomach ache, vomiting, reflux, eczema?)
Does your child sleep well?
How many hours a night?
Does he/she wake up during the night?
If so, why?
Any healers, helpers or therapies with which you are involved with your child? Please list:
Please describe some typical meals. Be as accurate and honest as possible.
Breakfast
Lunch
Dinner
Snacks
Liquids
What time does your child eat breakfast?
Lunch?
Dinner?
Snacks?
Other Liquids?
Who is responsible for the child's food preparation?
What percentage of the food is home cooked?
Where do you get the rest from?
The most important thing to me/us regarding feeding my/our child is:
Anything else you want to share?
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