Child Client First Time Evaluation Form

Client First Time Evaluation Form

For Children 12 Years Old and Under

Angela Frieswyk, Medical Herbalist & Holistic Nutritionist, Tauranga
Please Note the following:
1. Prior to your child's very first consultation, could you please fill-in this form and send it to me by clicking on the Submit Button at the bottom of the form.
2. Allow a good 10-15 minutes to complete the form.
3. Some questions on this form are marked as "required" by showing a red asterix to the right of the question heading. You will get an Error Warning in a red box at the top of the form if you have not answerred all the required questions. Please enter your answers for each of the required question, then press the blue Next Button.
4. At any time while completing this form, you can can step backwards through the various sections by clicking on the "Back" button at the bottom of each section of the form. You can make changes on what you have already enterred. Likewise, you can move forward through the form by clicking on the blue "Next" button.
5. All information entered by you is kept strictly confidential. The detail is used to allow me time to review your health basics and focus on priorities during your consultation.
6. If you have any recent/relevant blood tests or medical reports, please bring these with you (request a copy from your doctor’s clinic or specialist). As an alternative, you can electronically attach these reports at the end of this form.

Your Child's Personal Details:
Child's Name*

First NameLast Name
Age in years:*
Date of Birth*

DayMonthYear
Date
Child's Sex

FemaleMale
Parent/Guardian Name

First NameLast Name
Your Address*

Street Address

Street Address Line 2

City/TownState / Province

Postal Code
A Contact Land Line Phone Number

Area CodePhone Number
Mobile Phone Number
Please enter a valid phone number.
Your Email Address*

Confirmation EmailPlease confirm your email address again. This is a required check to confirm that you have entered the same email address.
Your Child's Doctors Name and GP Practice:
Referred by

Your Child's Health

Current complaints/symptoms, Medications, Supplements, Surgery & Dental Work
Please list current complaints/symptoms and rate severity: (1 to 10 scale, 10 being the most severe)
Please tell me any additional information about your child's health
Your Child's Medications/Supplements

Enter details on all your child's Medications. When listing your child's medications, please include the following details for each medication:
1. Medication name
2. Dose
3. How long the child has used it
4. Why it was prescribed (if known).
Enter medications details
Enter supplement details
Surgery History

Please list any surgery procedures your child has had and the age of your child when this surgery was undertaken.
List any surgery procedures details
Dental Work

Please provide details on braces, fillings, or dental problems that need attending to:
Dental details

Cigarette Smoking Household

Please answer these questions if you are or other people in your household have been a cigarette smoker.
Does your child live in a non-smoking household?*

YesNo
If the child is exposed to Cigarette Smoking, please provide more details e.g. how often, what is the period of exposure.

Sleep Questions, Stress Levels and Learning Disabilities
Sleep Related Questions
How is your child sleep? Select options that describe your child's sleep patterns.*

RestfulRestless / Wakes up oftenHard to get to sleepBad dreams
Other Sleep Symptoms?
What time does your child usually go to sleep?*

Hour Minutes

AM/PM Option
What time does your child usually awake?*

Hour Minutes

AM/PM Option
Is your child's bedroom Dark or Light?*

DarkQuite Light
Your Child's Stress Levels and Reasons for Stress
Please rate your child's current stress level (on a scale of 1 to 10, 10 being the highest).*
What if any is the main reason(s) for your child's stress?
Does your child have any learning disabilities?

NoYes
If yes please give brief detail: eg ADHD, dyslexia, etc.

Family Illnesses

Please provide details on any illnesses in the immediate family.
Mother Illnesses
Father Illnesses
Siblings Illnesses

Client First Time Evaluation Form