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ChiIdren's HeaIth Check Questionnaire
All details will be held private & confidential
CIick in the boxes to make your seIections, and cIick at the start of each orange Iine to see the bIue
highIight which aIIows you to type text.
Parent or Guardian's PersonaI DetaiIs Today's Date:

Title: Dr Mr Ms Mrs Miss Other:

Date of Birth:

Full Name:

Home Telephone Number:



Address:

Postcode:

How did you hear about ZNutrition?



Work/Mobile Number:


ChiId's PersonaI DetaiIs

Full Name:


Date of Birth:

Address (if different from above):

Postcode:


Doctor's Name & Address:


Postcode:

Doctor's Telephone Number:



Do you give permission for your child's GP to be contacted?

Yes No

Emergency Telephone Number:


What is/are your main reason(s) for seeking nutritional support for
your child?



Have you seen any other healthcare
professionals regarding your child's
symptoms, including your GP?

Yes No

s your child currently undergoing any medical treatment?

Yes No f yes: Please give details:


s your child currently following a
medically prescribed diet?

Yes No
Height: Weight: Age:

Does your child enjoy food in general?
Yes No
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edications & SuppIements
Prescribed Drugs
edication Dose HeaIth Condition Being
Treated/Reason
Frequency Duration Current Past
e.g. Ritalin 5 mg ADHD 1 /day 3 years










Over-the-Counter edications
edication Dose HeaIth Condition Being
Treated/Reason
Frequency Duration Current Past
e.g. Calpol 2 tsps Fever 1 /week 6 months










SuppIements t is helpful if you bring any supplements your child is are taking with you
SuppIement Dose HeaIth Condition Being
Treated/Reason
Frequency Duration Current Past
e.g. vitamin C 800mg immune system 1 /day 1 year










edicaI History
HeaIth Condition/Operation Age of Onset Duration anagement/Treatment
e.g. asthma age 3 1 year inhaler & diary-free diet






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FamiIy History
s there a history of heaIth probIems or disease in your chiId's famiIy?
FamiIy ember Condition FamiIy ember Condition

Mother




Father



Maternal Grandmother




Paternal Grandmother



Maternal Grandfather




Paternal Grandfather



Aunt(s)




Uncle(s)



Female Cousin(s)




Male Cousin(s)



Sister(s)




Brother(s)



Symptoms !lease check all that apply
PotentiaI edicaI ReferraI
Unexplained Pain Chest Pain Numbness Constipation Paralysis Depression
Blood in Sputum Diarrhoea Persistent Nose Bleeds Blood in Stool Difficulty Swallowing
Shortness of Breath Blood in Urine Vaginal Discharge Slurred Speech Blood in Vomit
Excessive Thirst Unexplained Bruising Blurred Vision Dizziness Frequent Urination
Headaches Migraines Unable to Gain Weight Unable to Lose Weight Unexplained Rash
Loss of Appetite Unexplained Weight Loss
Weight, SIeep, & ood
Fluctuating Weight Lose Weight Easily Gain Weight Easily Sudden Weight Loss
Sudden Weight Gain Lost Weight Recently Gained Weight Recently Weight around Middle
Weight on Hips & Thighs Difficulty Losing Weight Asleep After Midnight Difficulty Waking Up
Difficulty Falling Asleep Disordered Sleep Pattern Sleepy in the Day Un-refreshed After Sleep
Need More Than 8 Hours Need Less Than 7 Hours nsomniac Wake Up n Night
Bed Wetting Sleep Walking Aggression/Anger Anxiety Stressed Depression
Frustration Hyperactive rritable Mood Swings





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Digestion
Fast Eater Bloating Can't Tolerate Fatty Meals Dislikes Meats/Proteins Heartburn/Acid Reflux
Colic Frequent Hiccups Abdominal Discomfort Low Satiety after Eating Constipation
Diarrhoea Flatulence Anal rritation Black Stools Stools That Float Haemorrhoids
Pus/Mucous in Stool Frequent Foreign Travel Parasite Frequent Stomach Bugs
Frequent Vomiting/Sick after Feeding
Energy, nfIammation, & Detoxification
Fatigue Exhaustion Fluctuating Energy High Energy Acne Boils Warts
Asthma Cancer Frequent njury Conjunctivitis Crohn's Disease Cystitis
Thrush Dermatitis Diverticulitis Eczema Gastritis Gingivitis Hay Fever
Herpes Virus (e.g. Cold Sore) Hepatitis Hives rritable Bowel Syndrome Joint Pains
Frequent Colds/nfections Laryngitis Labyrnthitis Tonsillitis Nephritis Oesophagitis
Otis Media Ear nfections Pancreatitis Psoriasis Rhinitis/Frequent Runny Nose
Sinusitis Lupus Ulcers Gum Problems Urethritis Athlete's Foot Amalgam/Metal Fillings
Headaches Bad Breath Dark Circles Under Eyes Dark Coloured Urine Night Sweats
Frequent Air Travel High Exposure to Pesticides Oily Fish 3+ Times per Week Strong Body Odour
Eat Mostly Non Organic Foods Live in Highly Polluted Area Sensitive to Chemicals Tinnitus
tching Foot Pain Rashes Yellow Discolouration in Skin/Eyes
AIIergies & ntoIerances
Family History of Allergy Diagnosed Allergy History of Allergic Reaction Carry an EpiPen
Been Tested for Allergies Tested for ntolerances Diagnosed ntolerance tchy Throat
tchy Eyes Sneezing Tired After Eating Swollen Lips Swollen Throat Foggy Brain
Please list any foods or chemicals your child reacts to:
Hormone HeaIth - FemaIes OnIy (if appIicabIe)
Age of First Period:
Heavy Periods Light Periods Painful Periods Night Sweats Menstrual Migraine/Nausea
rregular Menses Menstrual nsomnia PMS
Hormone HeaIth - aIes OnIy
Undescended Testes
CircuIatory HeaIth
Anaemia Vegetarian Vegan Calf Pain Muscular Pain Faint on Standing
Nose Bleeds Diabetes Pain in Legs on Walking Shortness of Breath Palpitations


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&nique to Your ChiId
Learning Difficulties Competitive Low Attention Poor Memory Compulsive Docile
Broken Bones Anorexia Bulimia Frequently Cold Frequently Hot Protruding Eyes
Swollen Neck Big Appetite Small Appetite Often Thirsty Dry Hair Dry Skin
Nails Break/Peel Easily Cracked Lips Red Pimples Tops of Arms Dandruff Slow Healing
Morning Nausea White Marks on Nails Poor Sense Of Smell/Taste Licks Paint from Walls
Eats Stones/Sand Bowed Legs
PhysicaI Activity
Very Active Active Quite Active Sedentary
Type of Exercise Frequency Duration





Your ChiId's Diet
Does your child dislike any foods?
Which foods are your child's favourites?
What special diet(s) is/has your child following/followed?
Per Week Per Day
Food tem Quantity/Frequency Food tem Quantity/Frequency
Biscuits Pasta
Cakes/Pastries Pulses
Sweets Slices of Bread
Chocolate Chips
Pints of Cows' Milk Fruit
Red Meat (beef, pork, lamb) Vegetables
White Meat (chicken, turkey, game) Smoothie
Oily Fish (fresh tuna, sardines, trout) Squash
White Fish (pollock, cod, haddock) Concentrated Juice
Nuggets, Burgers, Sausages Fresh Juice
Eggs Tap Water
Cheese Filtered Water
Tomatoes Bottled Water
Carrots Fizzy Drinks
Peas Diet Drinks
Berries Sport/Energy Drinks
Cauliflower, Broccoli, Cabbage
Salads
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When cooking for your chiId do you:
Cook with vegetable oils? Cook with olive oil? Microwave food? Use ready prepared foods?
Add salt to your cooking? Cook for more than one? Enjoy cooking? Mainly buy organic produce?
Wash & peel non organic produce? Cater for a special diet? Eat out frequently? Get take-aways
Avoid additives & preservatives? Add artificial sweeteners to food? Add ketchup/mayonnaise to meals?
Prepare white bread, pasta, & rice? Use margarines? Choose low/reduced fat products?
Recently changed your child's diet? Lack ideas for healthy eating? s food shopping easy for you?
Was your chiId:
Breast fed? Formula Fed? Weaned before 6 months?
Food Diary
Day Time(s) eaI PIease Record Food/Drink ntake
Weekday 1



Breakfast









Lunch









Dinner










Snacks











Drinks





Day Time(s) eaI PIease Record Food/Drink ntake
Weekday 2



Breakfast









Lunch









Dinner










Snacks
















Drinks





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Day Time(s) eaI PIease Record Food/Drink ntake
Weekend
Day




Breakfast









Lunch









Dinner










Snacks










Drinks






AdditionaI Notes