Baby & Child Medical Questionnaire

Baby & Child Digestive Health Consultancy Consent Form

Name & Address
This name and address information is populated from your initial registration or previous forms. Any changes made will be updated for future forms.
Name of Parent/Guardian:*
Baby/Child's Forenames(s):*
Baby/Child's Surname:*
Address 1:*
Address 2:
Town:*
County:*
Postcode:*
Parent/Guardian Email:*
Parent/Guardian Mobile:*
Baby/Child's Personal Details
Baby/Child's Gender:*
Baby/Child's Date of Birth:*
DD slash MM slash YYYY
Baby/Child's Age:
Baby/Child's Doctor
Doctor's Name:*
Surgery Name:*
Surgery Address 1:*
Surgery Address 2:
Surgery Town:*
Surgery County:*
Surgery Postcode:*
Baby/Child's Current Height (Feet & Inches):*
Baby/Child's Current Weight (Stone & LBs):*
Health conditions/symptoms that you are seeking support for your baby/child?*
Does your baby/child have a diagnosed digestive issue? (YES/NO) If yes, please provide additional details.*
Does your baby/child have any allergic reactions to food or anything that has been diagnosed by a GP? (YES/NO) If yes, please provide additional details.*
Does your baby/child experience the following?
- Abdominal bloating
- Acid reflux
- Bloating after meals
- Burning pains in stomach or complaining of tummy pain
- Burning pain in throat
- Constipation
- Diarrhoea
- Diverticula
- Flatulence belching
- Flatulence rectal
- Frequent urging to stool
- Irritable Bowl syndrome
- N/A
How frequently does your baby/child go to the toilet?*
Irregular Bowel Movements*
Constipation*
IBS / Bloatedness*
Diarrhoea*
Food Cravings*
Mood Swings*
Skin Problems*
Allergies*
In the last 3 months, when your baby/child had pain or discomfort in the abdomen how often:
Did it get better after having a bowel movement?
Were your baby/child's bowel movements softer and more mushy or watery than usual?
Were your baby/child's bowel movements harder or lumpier than usual?
Did your baby/child have more bowel movements than usual?
Did your baby/child have fewer bowel movements than usual?
Food Frequency
My child is:*
- Breastfed
- Formula fed
- Being weened
- n/a
Fruit – What fruit and how many portions does your baby/child eat each day?
Fruit Portions
Vegetables – What vegetables and how many portions does your baby/child eat each day?
Vegetables Portions
How many slices of bread does your baby/child eat per week of the following?*
White Wholemeal Granary Rye Wheat free Gluten free
How many portions a week does your baby/child eat of the following?*
Pulses, beans, lentils etc. Beef Lamb Pork Chicken Turkey
How many portions a week does your baby/child eat of the following?*
Eggs Milk Yoghurt Cheese Cakes Chocolate
How many portions a week does your baby/child eat of the following?*
White Fish Tuna Salmon Trout Herring Sardines Mackerel
What grains does your child eat on a weekly basis:*
- Wheat
- Corn
- White Rice
- White Pasta
- Quinoa
- Millet
- Oats
- Rye
- Brown Rice
- Wholemeal Pasta
- Couscous
- Bulgar Wheat
- N/A
Eating Habits
- Skip breakfast
- Graze (small frequent meals)
- Regularly miss meals
- Eat constantly whether hungry or not
- Generally eat on the run
- Fussy eater
- Add salt to food
- Add sugar to drinks
- N/A
Fluids – Cans/Glasses per day of:
Fizzy drinks Cordial Fruit juice Sugar-free diet drinks Energy drinks Cow's milk Plant based milk Goat's milk Water (250ml) Baby Formula – Cow's Baby Formula – Goat's
Medication
Prescribed Medications & Nutritional Supplements – Please list any medications and nutritional supplements your baby/child take on a daily basis:*
Name of Medication What is it for? Daily Dose
Surgical procedures – Please add any information on operations/surgeries in the last 5 years:
What products do you wash your baby/child with that you put on their skin? (shampoo, soap etc).
What washing powder do you use for your baby/child?
Does your baby/child have contact with pets/animals:
Have you as a parent/guardian been under a lot of stress lately?
Has your baby/child had any stress or anxiety ?
Does your baby/child play outside much (see daylight)?
Does your child game in a dark room?
- Yes
- No
- N/A
Anything Else:
Additional Information – Please list below any further information about your health that you feel may be of importance to your treatment – if you would prefer to discuss this with your therapist in advance please call:
Where did you hear about us?*
Parents/Guardian Name*
Parents/Guardian Signature:*
Phone
This field is for validation purposes and should be left unchanged.

What a Typical Appointment Includes

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Fruit	Portions

Vegetables	Portions

Name of Medication	What is it for?	Daily Dose

Baby & Child Medical Questionnaire

Baby & Child Medical Questionnaire

Baby & Child Digestive Health Consultancy Consent Form

Name & Address

Baby/Child's Personal Details

Baby/Child's Doctor

In the last 3 months, when your baby/child had pain or discomfort in the abdomen how often:

Food Frequency

Medication

What a Typical Appointment Includes

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