The information supplied is held in the strictest confidence and will not be disclosed to a third party without your consent, other than exceptions noted in the separate confidentiality agreement.

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The information requested can be helpful but is not essential for your treatment. Please do not feel you need to answer anything that you would prefer not to. We can always discuss areas of importance during your  consultation. 

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I do however, need to know any medical conditions such as asthma, epilepsy, heart conditions etc as this will need to be taken into consideration when we work together.

 

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Full Name:

Date of Birth:

Address:

Telephone number:

Email:

Number of siblings names and ages:

 

 

Who does the child live with parents names?

 

Brief outline of the issue or issues:

 

What are parents/carers/clients hopes/expectations ?

 

When did the problem or problems start?

 

What makes it worse?

 

What makes it better?

 

Are there any worries about school?

 

Are there any worries about other family members health?

 

Current medical conditions?  date of doctor’s diagnosis where relevant.

 

Any current or recent medical treatment?

 

Medication list 

 

GP (Name, Address of Surgery):

 

Exercise undertaken

 

Way of Eating – (eating patterns for example skip breakfast eat lunch and dinner, and what types of food for example cereal for breakfast, Sandwich for lunch, pasta /pizza/takeaway for tea) 

 

Any sleep problems?

 

Any Allergies?

 

Any over the counter Medicine take regularly?

 

Any Supplements taken?

 

 

Any significant life events during the last year?

 

  

Parent/Carer SIGNATURE