Family with Children Health History
This Form Focuses on The Children In The Family
Name of Parent/Parents
Name and Ages of Children
Address
E-mail Address
Phone Number
Alternate Phone Number
Please list your main health concerns for your children. Be specific of concerns only apply to one child.
Other concerns or goals?
What is really working well for you and your children?
Any serious illnesses, hospitalizations/injuries?
Any food sensitivities that you are aware of?
Any unexplained symptoms (stomach ache, vomiting, reflux, eczema?)
Do your children sleep well?
How many hours a night?
Do they wake up during the night?
If so, why?
Any healers, helpers or therapies with which you are involved with your children? Please list:
Please describe some typical meals. Be as accurate and honest as possible.
Breakfast
Lunch
Dinner
Snacks
Liquids
What time do your children eat breakfast?
Lunch?
Dinner?
Snacks?
Other Liquids?
Who is responsible for the children'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 children is:
Anything else you want to share?
Submit Form
Should be Empty: