Child Nutrition Clinic Questionnaire

Child Nutrition Clinic Questionnaire

Let your exciting journey to better family health begin
Personal Information
Your name (parent/guardian)*

First NameLast Name
Your DOB (parent/guardian)*

MonthDayYear
Date
Yes, I am a MotherYes, I am a FatherYes, I am other legal guardian
Child name*

First NameLast Name
Your child's DOB*

MonthDayYear
Date
Child age*
Before first year, please write your little one's age in months (ex. 9 months). After 1 year in years and months (ex. 3y.o. and 2 months). For kids 12y.o+ only full years (ex. 12y.o.)
FemaleMale
Your Email*
example@example.com
Your Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your child's health programme

With Healthy Bunny Child Nutrition Clinic
Reason for seeking help from nutritionist:
Ex. Digestive concerns (specify: indigestion, cramps, constipation..)
Online (Google meet)Phone callWhatsApp
Please choose your program:
Medical History and Nutrition Questionnaire
Anxiety or Panic AttackArthritis (osteoarthritis or rheumatoid)AsthmaDiabetes: Type IDiabetes: Type IIPrediabetesADHDAutismEpilepsyKidney abnormalities or diseaseCongenital heart defectsHypo- or hyperthyroidismHepatitisHigh blood fats (cholesterol, triglycerides)Hypoglycemia (low blood sugar)NONE OF ABOVEOther
Provide further information if any
Please share your child's GP details below:
YesNo
DailyOccasionally (a few times a week)Rarely (a few times a month)Never
MumDad50/50Child eats most of the time in his/her childcareOther members of the family
IF other members, please specify:
What are your child's favourite foods?
Any foods your little one doesn't like?
Does your child have any food allergies or intolerances? If yes, list below
If yes, are these diagnosed by GP?
Does your child take any supplements or vitamins? If yes, list below
How energetic is your little one?

1

2

3

4

5

1 is Tired all the time, 5 is Very energetic
How much exercise is your little one having every day?

1

2

3

4

5

1 is No exercise, 5 is A lot of exercise
Your child's favourite exercise/sport activity:
Rate your child's sleep

(1 star bad sleep; 5 stars very good sleep)
Rate your child's stress levels and ability to cope with stress

(1 star stressed; 5 stars not stressed)
Rate your stress levels and ability to cope

(1 star stressed; 5 stars not stressed)
Rate your sleep

(1 star bad sleep; 5 stars very good sleep)
Rate your family's readiness for change

How willing are you to follow advice and implement protocols?
Top 3 things I should know about you and your little one
Formalities
Yes, add meNo, don't add me
How did you hear about our clinic?*
At ADB Nutrition has an online system in place for the safe exchange of information.

This is our standard way of practising and keeping all your sensitive information safe.

Please tick to say you agree with us registering you on this platform.

We will be sending you all forms and your plans via this system.

This is to comply with GDPR.

ADB Nutrition can provide more details if needed.

This is a requirement, so if you do not agree, we can not proceed with the booking.
Yes, add me
Yes
One's health and well-being are directly influenced by their nutrition and vice versa. By completing this form you accept that all mentioned information is correct and that you are accepting a service provided by your practitioner from ADB Nutrition (Child clinic Healthy Bunny) that is prepared based on the provided data.

Full details in the below-listed documents (you will be sent these documents to sign and read once you are on the client portal):

Disclaimer

Ts&Cs

Privacy Policy

It is your responsibility as a client of the clinic to read these documents carefully.
Date*

MonthDayYear
Date
Signature*
Should be Empty:

Child Nutrition Clinic Questionnaire

Personal Information

Your child's health programme

Medical History and Nutrition Questionnaire

Formalities