Children's Consult

First Name

Last Name

Date of Birth

Age

Parent's Email

What is your child’s primary health concern?

When did it start?

What makes it better, worse?

Have they had it before?

Any health or lifestyle changes with your child or your family prior to this?

How does your child sleep?

What does your child eat (mostly)?

How’s their digestion?

Does your child do any physical movement? Describe.

Does your child have down time? Time to relax and quiet their minds?

How’s your child’s energy and moods?

Anything going on that I should know about?

List any medications, including natural ones. List how long they’ve been taking it and for what purpose. Is it helping?

Vaccinations: any effects from any? If so, please explain.

Can you child take herbs?

Can they handle pills or liquid? They can be crushed up in applesauce. There are a few children’s formulas that are not as intense tasting.

KateStewart
Wellness, LLC