Minor Intake Form

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Of child
  • Child's address (if different to yours)
As they are going to receive a distance session, Eloise loves to have lots of information on different aspects of your life which may come up in sessions.
Also, please mention any medical tests you have had in the last year.
Any injuries, accidents, surgeries etc and dates...
If so when?
Or have seen in last 6 months, or planning to see...
Please give dates

Please mention any issues in each category (leave blank if no problems). Also, mention how frequent the issues are? eg once a month, occasionally, every week, constantly etc

Acid reflux, constipation, diarrhoea, excessive or no appetite, gall stones, gas, haemorrhoids, heartburn, hernia, cholesterol, indigestion, irritable bowles, nausea, parasites, poor digestion, poor sense of taste, stomach or intestinal pain etc
Allergies, asthma, bronchitus, colds, chest tightness, congestion, dry cough, emphysema, hay fever, nasal issues, poor sense of smell, pneumonia, shortness of breath, sinus issues, wet cough, wheezing
Anemia, angina, blood clots, chest pain, cold hands/feet, dizziness, easily bruised, heart attack, heart disease, heart palpitations, hypertension, hypotension, oedema, poor blood clotting, poor circulation, restlessness, slow heart rate, stroke, sweaty hands/feet
Cystitus, difficulty or painful urinating, incontinence, kidney infections, kidney stones
Dyslexia, developmental or growth issues, epilepsy, head injuries, learning disorders, MS, muscular dystrophy, nervous disorders, numbness, tingling, poor concentration
Arm or leg weakness, artificial joints, broken or fractured bones, difficulty walking, fascial pain, joint swelling, loss of balance, arthritis (name type), pins, poor circulation, jaw pain, body weakness
Please name any body parts which are painful. Please let me know which side L or R.
Dental problems, speech issues, swallowing problems, dry eyes, dry mouth, eye pain or problems, headaches, migraines, nose bleeds, hearing issues,
Acne, eczema, psoriasis, shingles, skin conditions, soft or brittle nails
Genital pain, problems urinating...
Nipple discharge, painful periods, heavy flow, PMS, regularity of monthly cycle.
Cancer, dizziness, fibromyalgia, herpes, swollen glands, thyroid issues, tremers
Mention any specific areas of pain. Giving a score of 1-10. 1: slight discomfort, 10: you need to go to the hospital

Mention any anxiety, depression, difficulty making plans or decisions, easily angered, obsessive tendencies
Have they had Covid? Have they had any vaccines? If so which one and give dates. Also let me know your emotional state/feelings on the whole thing. Any stress from the last few years?

How much time do they have to themselves to relax? Any hobbies? Exercise? (What and how often)
How restful is their sleep? How many hours do they normally sleep?

Anything they are excited about in life? Or for the future?
Anything else which doesn't fit on the form which feels relevant or important?