New Nutrition Patient Form-Child

New Nutrition Patient Form - Child (Ages 12 and Younger)

Welcome to our New Nutrition Patient Form for children aged 12 and younger. This form is designed to gather comprehensive health and nutritional information about your child to assist our team in creating a personalized care plan tailored to their specific needs. It covers various aspects, including personal information, health history, dietary habits, symptoms checklist, and consent for treatment. Your responses will enable us to understand your child's health better and provide the most effective nutritional advice and support. Please take your time to fill out the form as accurately as possible. If you have any questions or need assistance at any point, feel free to contact us. Thank you for entrusting us with your child's nutritional health care.

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Child's Personal Information

Your Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Email(Required)

Phone(Required)

Height(Required)

Weight(Required)

Supplements and Medications

Is your child taking any supplements? If yes, please explain.

Is your child taking any medications, or has taken any in the past (including antibiotics)? If yes, please explain.

Symptoms Checklist

If your child has any of these symptoms present, please rank the symptoms present, please rank the symptom as Mild (1-2x/month), Moderate (almost weekly), or Severe (almost daily or multiple times a week). if options are indicated, please circle which symptom applies best.

Stress & Emotions

Assess your child's stress and emotional symptoms below:

Challenges with getting or staying asleep:

Mild

Moderate

Severe

Vivid dreams or nightmares:

Mild

Moderate

Severe

Dizziness upon rising:

Mild

Moderate

Severe

Bedwetting:

Mild

Moderate

Severe

Number of hours asleep each night:(Required)

Sleep

Assess your child's sleep-related symptoms below:

Unable to relax:

Mild

Moderate

Severe

Nervous stomach:

Mild

Moderate

Severe

Irritable or angry:

Mild

Moderate

Severe

Moody or easily frustrated:

Mild

Moderate

Severe

Inability to concentrate, confusion:

Mild

Moderate

Severe

Immune

Assess your child's immune-related symptoms below:

Subject to colds, asthma, bronchitis:

Mild

Moderate

Severe

Itchy eyes, ears, nose:

Mild

Moderate

Severe

Allergies (food, enviroment, etc.):

Mild

Moderate

Severe

Crust in the eyes upon waking:

Mild

Moderate

Severe

Postnasal drip or excessive drainage:

Mild

Moderate

Severe

Frequent sneezing:

Mild

Moderate

Severe

Earaches or infections (past or present):

Mild

Moderate

Severe

Excessive earwax:

Mild

Moderate

Severe

Digestion

Assess your child's digestion-related symptoms below:

Appetite reduced or excessive:

Mild

Moderate

Severe

Clammy hands or feet:

Mild

Moderate

Severe

Frequent vomiting:

Mild

Moderate

Severe

Gas (either just air or foul smelling):

Mild

Moderate

Severe

Chronic stomach aches (esp. after meals):

Mild

Moderate

Severe

Constipation or diarrhea:

Mild

Moderate

Severe

Headaches or migraines:

Mild

Moderate

Severe

Burning or itching anus:

Mild

Moderate

Severe

Craves sweets or carbohydrates (breads, pastas, etc.):

Mild

Moderate

Severe

Unexplained weight gain or loss:

Mild

Moderate

Severe

Skin

Assess your child's skin-related symptoms below:

Eczema or bumps on the back of arms:

Mild

Moderate

Severe

Dry, itchy skin and/or feet:

Mild

Moderate

Severe

Molluscum:

Mild

Moderate

Severe

Diaper rashes:

Mild

Moderate

Severe

Frequent rashes on body:

Mild

Moderate

Severe

Minerals

Assess your child's mineral-related symptoms below:

Muscle cramps or Charlie horses:

Mild

Moderate

Severe

Restlessness:

Mild

Moderate

Severe

Eye twitching:

Mild

Moderate

Severe

Doesn't remember dreams:

Mild

Moderate

Severe

Number of bowel movements/day:

Stool Consistency - Soft/Solid, Loose, Pebbles:

Medical History and Details

Has your child had/Does your child currently have a medical diagnosis?

ADD/ADHD

Chicken Pox

Colix

Congenital Defects

Fever Blisters

Tonsilitis

Appendicitis

Jaundice

Measles

Mumps

Pneumonia

Seasonal Allergies

Whooping Cough

Anxiety or Depression

Other

Please mark the age of onset, and please add additional details below.

Age of diagnosis onset and/or extra details, as needed:

Has your child had tubes in his/her ears? If yes, please explain.

Does your child get adjusted by a chiropractor?

Regularly

Sometimes

If yes, please explain what age your child started care, as well as the Chiropractor's contact information.

Did mom receive chiropractic care during her pregnancy?

Yes

How was your child born?

Vaginally

Planned Cesarean Section

V-BAC

Emergency Cesarean Section

Was medication used during labor?

Epidural

Pitocin

Other

Were there any complications during labor/birth?

How did your baby get his/her nutrients?

Breastfed

Homemade Formula

Store-Bought Formula

Please note how long for each, if applicable. Any additional comments, please explain:

Has your child had any vaccinations?

Yes

If yes, please explain the following: name of vaccine, child's age upon receiving vaccine, and year vaccine was given.

If yes, did your child have any adverse reactions post receiving the vaccinations ( ex: fever, fussiness, loss of appetite, nausea, seizures, non-stop crying, lethargy)?

Additional Information

What are your child's hobbies?

Please list the 3 health goals in order of importance:

Signature

Consent(Required)

I agree to the privacy policy and the terms of service.

By checking this box, I, the undersigned, confirm that I have read, understood, and agree to the Privacy Policy and the Terms of Service provided by East Cobb Spine & Sport Chiropractic. I hereby consent to the collection, storage, and use of my and my child's personal and health information for the purpose of receiving nutrition and health services. I understand that my consent is voluntary and that I may withdraw it at any time by contacting info@drbobbacon.com or 1-404-973-0188. I acknowledge that the information provided on this form will be used to assess and provide personalized health recommendations for my child and that all information will be treated with confidentiality in accordance with applicable laws and regulations. I affirm that I am the parent or legal guardian of the child named in this form and have the authority to provide this consent.

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New Nutrition Patient Form-Child