Nutritional Health Questionnaire
for Babies and Children

This questionnaire is designed to provide your nutritionist with all the information necessary to build you an individual nutritional programme specifically tailored to your needs. Please answer the questions as accurately as you can.

Step 1 of 18 – Child’s Details

Comments

This field is for validation purposes and should be left unchanged.

Child's Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Child's/Baby's Age(Required)

Years/Months

Child's/Baby's Weight(Required)

kgs

Childs/Baby's Height(Required)

Metres

Child's/Baby's Ethnicity(Required)

Home Phone Number

Parent/Carer Work Number

Mobile Phone Number(Required)

Fax Number

Address

Street Address Address Line 2 City County / State / Region Post Code

Main Reasons For Visit(Required)

Mother's Name

First Last

Age

Health Problems

Are you the Birth Mother?

Father's Name

First Last

Age

Health Problems

Are you the Genetic Father?

Any Brothers or Sisters?

Sex

Age

Health Problems

Are there any particular illnesses and/or allergies in the family? Please state which

(e.g. heart disease, diabetes, asthma, eczema, hayfever, food allergies etc)

Who lives at home with the child?

Does your child have access visits to a parent?

Is your child part of a stepfamily?

Does your child attend?

Day Nursery

Child Minder

Playgroup

School

Special School

Occupation of Mother

Occupation of Father

Please detail if there are any pets at home

GP's Name

GP Address

Street Address Address Line 2 City County / State / Region Post Code

Phone

Is your GP aware you are consulting a nutritional therapist?

Yes

Are you happy for your GP to be kept informed?

Yes

Any other health professionals involved in your child's care?

Previous pregnancies including any miscarriage or neo-natal death

Contraceptive history e.g. the pill, coil, spermicides

When last used and how long for?

Did you follow a pre-conceptual care programme (e.g. Foresight) to optimise health?

Yes

Did you conceive this child naturally?

Yes

Did you receive any fertility treatment prior to conceiving?

Yes

Details:

Did you experience any complications during pregnancy?

Yes

Did you experience any of the following during your pregnancy?

Bleeding

Excessive Water Retention

Nausea/Morning Sickness

Pregnancy Diabetes

Pre-Eclampsia

High Blood Pressure

Thrush

Cystitis

Tick yes to all that apply

Did you receive any treatment for any of the above?

Yes

If yes, what treatments and for which?

Did you suffer any illnesses in the pregnancy, e.g. viruses, operations etc

Any Treatments?

Please detail any medical tests during pregnancy e.g. how many scans, blood tests etc and what stage?

Did you take any of the following during your pregnancy?

Please state how much and at what stage in pregnancy

Cigarettes- Yes or No

Alcohol- Yes or No

Tea, Coffee, Cola- Yes or No

Prescribed medication- Yes or No

E.g. Antibiotics, Anti-Depressants, Anti-Nausea

Over the counter drugs- Yes or No

Street Drugs- Yes or No

Nutritional Supplements- Yes or No

Did you travel abroad much prior to or during pregnancy- Yes or No

Where and when?

How active was the baby before the birth?

Did you suffer from thrush/cystitis after delivery? Yes or No

State which and When

Any additional information about this pregnancy?

Was your appetite affected? Increased/Decreased

At what stage of the pregnancy?

Did you lose or gain excessive weight?

How often did you eat meat/fish in a week?

Did you exclude any of the following foods?

Yeast

Eggs

Fish

Meat

Did you exclude any of the following foods?

Wheat

Dairy Products

Additives

Citrus Fruit

Sugar

Any other food that you excluded?

Did you "go off" any foods?

If so, what?

Did you crave any foods or non-foods?

If so, what?

Was this your first labour?

Yes

Duration of Pregnancy (normal gestation is 40 weeks)

Was this your first labour?

Yes

Were you induced?

Yes

Length of Labour?

Medications during labour e.g. gas and air, epidural, pethidine

Type of Birth?

Normal Vaginal Delivery

Forceps or Ventouse

Planned Cesarean

Emergency Cesarean

Water Birth

Place of Birth?

Hospital

Home

GP Unit

Other

Birth Weight

grams

Birth Head Circumference

Birth Length

Birth centitle on growth chart, e.g. 50th, 25h etc (Please bring baby book)

APGAR Score

Did your baby suffer from:

Jaundice

Oxygen Deficit

Any other problems

Did your baby require special care?

Yes

Why/Duration?

Additional Information about labour/birth

Has your child suffered infections requiring antibiotics?

Yes

If yes, please give age, illness and treatment

Does/Has your child take/taken any other prescribed medication?

Yes

If yes, please give age, illness and treatment

Does your child take over the counter medications?

Yes

If yes, which and for what? e.g. Calpol or Anti-histamines

Has your child ever been referred to a specialist?

Yes

If yes, please expand (e.g. Asthma, Coeliac Disease, Anaemia)

What tests has your child had by GP, Specialists, other?

Has your child received a medical diagnosis of any condition?

Yes

If yes, please give age, reason and type of specialist

Have you sought 'alternative' health care advice for your child e.g Homeopath, Cranial Osteopath

Yes

Any other medical information?

Has your GP, Health Visitor or any other medical practitioner ever expressed concern regarding your child's development?

Yes

If yes, please expand e.g. speech, learning, walking etc

Have there ever been any hearing problems?

Yes

Has your child's growth pattern been 'normal' e.g. Height, Weight, Growth Centile

Yes

If no, please detail

Has your child received the recommended standard immunisations?

Yes

If no, please detail those given and those excluded and why

Has your child ever had an adverse reaction to any vaccine?

Yes

If yes, please expand

Has your child had any of these infectious diseases?

Whooping Cough

Measles

Chicken Pox

Mumps

Rubella

Scarletina

Herpes

Tick all that apply now

Poor Eyesight

Rashes

Mouth Ulcers

Diarrhoea

Conjunctivitis/Sticky Eyes

Thrush

Chest or Urinary Infections

Dry, Flaky Skin

Frequent Colds/Infections

Nose Bleeds

Near Sightedness

Tooth Decay

Muscle Cramps/Pain

Sweaty

Sore Joints

Excessive Tiredness

Thin Hair/Hair Loss

Chilblains

Dry Skin

Easy Bruising

Slow Wound Healing

Weak Muscles

Fatigue on exertion

Nappy Rash

Red Pimples on skin (E.g. Upper Arms)

Frequent Colds

Frequent Infections

Bleeding Gums

Lack of Energy

Sore Eyes

Sore Muscles

Poor Concentration/Memory

Insomnia

Learning Difficulties

Tummy Aches

Constipation

Regular Pins and Needles

Eye Problems

Bed Wetting

Poor Hair Condition

Slow Learning

Sore Lips

Eczema/Dermatitis

Tendency to Allergies

Poor Sleeper

Easily Distracted

Headaches or Migraines

Irritability

Tendency to depression

Muscle Tremors

Lethargy

Short Attention Span

Loss of Appetite

Grinds Teeth

Anxiety or Tension

Nausea or Vomiting

Swollen ankles or Hands

Muscle Pains

Nervous or Depressed

Fits/Convulsions

Pins and Needles

Slow Growth

Pale Skin

Breathlessness

Drowsiness

Joint Pains

Brittle Nails

Poor Sleep

Anxiety

Colic

Hyperactivity

Muscle Weakness

Slow Learning

White spots on nails

Prefers strong, salty flavours

Moody

Growing Pains

Sore Knees

Dizziness

Diabetes

Dermatitis

Family History of Cancer

Visual Defects

Skin Disorders

Addicted to Sweet Foods

Depression

Irritability

Needs frequent Meals

Excessive Thirst

Tick all that previously applied

Poor Eyesight

Rashes

Mouth Ulcers

Diarrhoea

Conjunctivitis/Sticky Eyes

Thrush

Chest or Urinary Infections

Dry, Flaky Skin

Frequent Colds/Infections

Nose Bleeds

Near Sightedness

Tooth Decay

Muscle Cramps/Pain

Sweaty

Sore Joints

Excessive Tiredness

Thin Hair/Hair Loss

Chilblains

Dry Skin

Easy Bruising

Slow Wound Healing

Weak Muscles

Fatigue on exertion

Nappy Rash

Red Pimples on skin (E.g. Upper Arms)

Frequent Colds

Frequent Infections

Bleeding Gums

Lack of Energy

Sore Eyes

Sore Muscles

Poor Concentration/Memory

Insomnia

Learning Difficulties

Tummy Aches

Constipation

Regular Pins and Needles

Eye Problems

Bed Wetting

Poor Hair Condition

Slow Learning

Sore Lips

Eczema/Dermatitis

Tendency to Allergies

Poor Sleeper

Easily Distracted

Headaches or Migraines

Irritability

Tendency to depression

Muscle Tremors

Lethargy

Short Attention Span

Loss of Appetite

Grinds Teeth

Anxiety or Tension

Nausea or Vomiting

Swollen ankles or Hands

Muscle Pains

Nervous or Depressed

Fits/Convulsions

Pins and Needles

Slow Growth

Pale Skin

Breathlessness

Drowsiness

Joint Pains

Brittle Nails

Poor Sleep

Anxiety

Colic

Hyperactivity

Muscle Weakness

Slow Learning

White spots on nails

Prefers strong, salty flavours

Moody

Growing Pains

Sore Knees

Dizziness

Diabetes

Dermatitis

Family History of Cancer

Visual Defects

Skin Disorders

Addicted to Sweet Foods

Depression

Irritability

Needs frequent Meals

Excessive Thirst

Please Tick all that apply now (Miscellaneous Symptoms)

Earache

Cattarrh

Colic

Excessive Crying

Aggression

Constant Runny Nose

Snoring

Poor Co-ordination

Head Banging/Rocking

Sensitivity to Noise

Phobias

Shows no Fear

Recurrent Chest Infections

Threadworms

Obsessive Behaviour

Mood Swings

Thrush

Night Terrors

Disturbed Sleep

Please Tick all that previously applied (Miscellaneous Symptons)

Earache

Cattarrh

Colic

Excessive Crying

Aggression

Constant Runny Nose

Snoring

Poor Co-ordination

Head Banging/Rocking

Sensitivity to Noise

Phobias

Shows no Fear

Recurrent Chest Infections

Threadworms

Obsessive Behaviour

Mood Swings

Thrush

Night Terrors

Disturbed Sleep

Please Tick all that apply now (Specific Disorders)

Asthma

Eczema/Dermatitis

Hayfever

Food Allergies

Scabies

Dyslexia

Dyspraxia

Cerebral Palsy

ADD/ADHD

Autism/Autism Spectrum Disorder

Asperger’s Syndrome

Epilepsy

Arthritis/Still’s Disease

Crohn’s Disease

Phenylketonuria

AIDS

Downs Syndrome

Cleft Palate

Heart Disease

Sickle Cell Anaemia

Cystic Fibrosis

Haemophilia

Cancer

Please tick all that previously applied (Specific Disorders)

Asthma

Eczema/Dermatitis

Hayfever

Food Allergies

Scabies

Dyslexia

Dyspraxia

Cerebral Palsy

ADD/ADHD

Autism/Autism Spectrum Disorder

Asperger’s Syndrome

Epilepsy

Arthritis/Still’s Disease

Crohn’s Disease

Phenylketonuria

AIDS

Downs Syndrome

Cleft Palate

Heart Disease

Sickle Cell Anaemia

Cystic Fibrosis

Haemophilia

Cancer

Please Tick all that apply now (Child's Personality/Behaviour)

Nervous

Unhappy

Temper Tantrums

Impulsive

Excitable

Nail Biter

Irritable

A ‘Holy Terror’

Restless

Tough

Emotional

‘All over the place’

Contented

Very ‘Good’

Wide Awake

Tidy

Messy

Clumsy

Please tick all that previously applied (Child's Personality/Behaviour)

Nervous

Unhappy

Temper Tantrums

Impulsive

Excitable

Nail Biter

Irritable

A ‘Holy Terror’

Restless

Tough

Emotional

‘All over the place’

Contented

Very ‘Good’

Wide Awake

Tidy

Messy

Clumsy

Please tick all that apply now (Lifestyle Factors)

Plays well alone

Easily Distracted

Learning Difficulties

‘Gifted’ Child

Lazy/Lethargic

Sleepy

Popular

Sociable

Tip Toes

Affectionate

Rejects Affection

Agile

Please tick all that previously applied (Lifestyle Factors)

Plays well alone

Easily Distracted

Learning Difficulties

‘Gifted’ Child

Lazy/Lethargic

Sleepy

Popular

Sociable

Tip Toes

Affectionate

Rejects Affection

Agile

How much time per day does your child watch TV?

How much time per day does your child use a computer? (including school and home)

How much exercise does your child have in a week?

What sports do they play?

Any Activity hobbies/clubs (e.g. Dancing)

Does your child chew food well?

Yes

Does your child suffer from bad breath?

Yes

Does your child suffer tummy upsets?

Yes

Does your child suffer with an itchy bottom?

Yes

Does your child have a daily bowel movement?

Yes

Does your child suffer from diarrhoea?

Yes

Does your child suffer from constipation?

Yes

Does your child suffer from bloating/excessive wind?

Yes

Are the stools:

Normal

Pale

Offensive

Floating

Other

Does your child suffer frequent colds, coughs, infections?

Yes

Does your child have:

Eczema

Asthma

Hayfever

Arthritis

Does your child suffer from food sensitivity?

Yes

Have you noticed any adverse reactions in your child after eating certain foods?

Yes

If yes, state which foods and what reactions

Does your child live in a city or by a busy road?

Yes

Does your child live in a smoky atmosphere?

Yes

Does your child usually drink filtered or bottled water?

Yes

Does your child eat non-organic foods?

Yes

Is the main home near to:

Pylons

Mobile Phone Mast

Factory

Patrol Station

Agricultural Land

Flight Path

Does your child have a TV in their room?

Yes

Does your child have a computer in their room?

Yes

Does your child have a mobile phone which is used regularly?

Yes

Did you breast feed at all?

Yes

If yes, for how long?

Did you take any of the following whilst breastfeeding:

Caffeine

Cigarettes

Alcohol

Did you require any medications whilst breastfeeding?

Yes

If yes, Which?

Did you bottle feed at all?

Yes

From what age?

Which formula?

What, if any, special formula were required?

e.g Soya, Casein Free

How old was your baby when you started weaning onto solids?

Which Foods were introduced and in what order?

Food

Any Reactions

Age

At what age did you introduce Wheat

Any Reactions

Age

At what age did you introduce Cows Milk

Any Reactions

Age

At what age did you introduce Egg

Any Reactions

Age

At what age did you introduce Peanuts

Any Reactions

Age

At what age did you introduce Citrus Fruit

Any Reactions

Age

Did you offer ready-made baby foods?

Yes

At what age?

Would you describe your child's appetite as

Good

Medium

Poor

Is your child a 'fussy' eater

Yes

Is your child currently following a specific dietary regime?

Are there any foods that your child craves?

Are there any foods that your child dislikes intensely?

Do you go out of your way to avoid giving foods containing preservatives and additives?

Yes

Do you avoid giving foods that contain sugar?

Yes

How many cans of fizzy drinks does your child drink in a week?

How many times a week does your child have meals containing fried or fast foods?

e.g Fish Fingers, Mcdonalds etc

How many portions daily of fruit and vegetables does your child have?

How many slices of bread or rolls does your child eat in a week?

Do you normally eat white or wholemeal rice, pasta and flour?

Does your child eat at nursery or at school?

Yes

If yes, please describe this food/drink

Does your child take a 'lunch box'?

Yes

What nutritional supplements does your child take on a daily basis?

Nutritional Health Questionnaire
for Babies and Children

Did you take any of the following during your pregnancy?

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Nutritional Health Questionnaire for Babies and Children

Did you take any of the following during your pregnancy?

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Nutritional Health Questionnaire
for Babies and Children