Patient questionnaire (child)

Where did you hear about Bury Homeopaths?

Full Name (child): *

Address: *

Postcode: *

Age and Date of Birth (child): *

Contact Number: *

Email: *

GP’s Surgery: *

Please state the main reasons for seeking homeopathic/naturopathic treatment (list as a timeline, i.e. child's health concerns in chronological order, with ages of when you first noticed symptoms & what they’ve been treated with below): *

Details of current medications, vitamin supplements:

Overall Health

During pregnancy, any problems? (anaemia, antibiotics, vaccinations etc):

Birth (vaginal, C-section, complications):

Baby 0-6 mths (breast or bottle fed, eczema, colic, other concerns)

6-18 mths (digestive problems, illnesses, food intolerances):

Toddler 18mths-3 yrs (illnesses, antibiotics, development issues):

3-12 yrs:

Teens:

Please note any other illnesses, concerns not covered, hospital visits, blood test results etc:

Please list vaccinations or antibiotics taken (date and reason):

Diet and Digestive Issues

Please enter any diet info e.g. vegan, vegetarian, meat or fish

Food allergies or intolerances

Any digestive issues (constipation, IBS, bloating, pain):

Please provide details of close relatives’ health status/illnesses if known, including cancer, diabetes, tuberculosis, mental illness, asthma, eczema, hay fever, etc:

Father:

Mother:

Brothers and Sisters:

Cancellation policy

Bury Homeopaths operate a 48-hour cancellation policy. If you cancel an appointment over 48-hours in advance, you will not be charged. If you cancel within 24 hours, you will still need to pay for the appointment in full. However, we recognise that emergencies happen and we will try to be accommodating in such circumstances.

Please Sign & Date

To sign this form, please enter your full name: *

Select today's date *

Bury Homeopaths keep all medical, patient information confidential and in a secure environment. Records will be kept for a maximum of 7 years from your last consultation date, as authorised by ANP, unless you request otherwise.

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Cancellation policy

Please Sign & Date

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