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Cell Phone Number
Home Phone Number
Child's Date Of Birth
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What is your heritage? (Eastern European, Italian, etc.)
Hobbies - Passions - Interests
Please List All Major Health Concerns and Symptoms In Order of Importance. You Can List as many as you need to.
Was your child given all the vaccines, on schedule? If not, please specify which ones you didn't give or which schedule you used.
Did you notice any reactions to the vaccines? Rash, lethargy, fever, etc.
Which Types of Doctors and Practitioners Have You Been To In The Past?
Describe The Treatments They Gave You and Whether or Not They Were Effective?
When Is The Last Time Your Child Really Felt Good?
Please List Any Health Problems You Can Remember Your Child Having, Especially If They Were Chronic and/or Recurring.
Do you feel there was 1 or Multiple TRIGGER EVENT(s) that contributed or led to your current symptoms/illness/diagnosis? If so, what were they?
Has your child ever been constipated? (less than 2 bowel movements daily) If so, for how long?
Have you ever given or done anything for constipation? (laxatives, enemas, etc.)
Have your child ever been tested for Heavy Metals?
Have your child ever been tested for Parasites?
Have your child ever had your vitamin, mineral and enzyme levels tested?
Please list any and all surgeries your child has had along with the Dates:
Has your child taken antibiotics more than 6 times in your life? What kinds of issues do you remember taking them for?
Does your child have trouble falling asleep? If So when do you remember first having trouble?
Do your child have trouble staying asleep? If So when do you remember first having trouble?
How does your child feel when they first wake up? (well-rested, still tired, achy, nauseous, etc.)
Please list ALL medications they are CURRENTLY taking, along with the dosage, how often, and for how long:
What symptoms, if any, do you feel are side effects of the medications?
Please List ALL Supplements they are currently taking, including the brand names, how much of each, and how often:
Do you eat out during the week? If so, how many times a week and what do you usually eat?
Does your child eat nuts, seeds, beans and grains? If so, which ones and how often?
Please list the sports or outdoor activities your child enjoy or regularly participate in.
Please List the 10 Most Un-Healthy Foods (what you deem to be the worst) You Eat Each Day/Week. Please put the foods you feel guilty about eating (if any) or the ones that you know don't make you feel great. The more details the better. :)
Please List the 10 Healthiest Foods You Eat Each Day/Week.
Please List an Average Day's Meals and Drinks and What Time.
What Packaged "Foods" do you typically have in your cupboards and what Brand Names are they? (Brand names are very important here) (Crackers, chips, snacks, bars, cookies, mac & cheese, pasta, etc.)
What Jars or Cans of "Food" do you have in your cupboards and what brands are they? (Brand names are very important here) (Soups, sauces,tuna, etc.)
What foods do you typically keep stocked in your Fridge and Freezer? (Dairy, frozen meals, meats, etc.)
Please put anything else here that you want to tell me or talk about when we speak.
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