Minor Intake Form Leave this field blank First Name: (Required) Last Name: (Required) Date of Birth: (Required) Of child Address: Child's address (if different to yours) Doctor's Name & Address: (Required) Sexuality: Gender: (Required) Please answer all the questions about your child to the best of your ability. 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. School info: (Required) Describe the problem(s) for your child which you are coming to Eloise for. Please include any dates when problems started: If you have sought medical supervision for the above, please give any information: Also, please mention any medical tests you have had in the last year. Past medical history: Any injuries, accidents, surgeries etc and dates... Any medications, supplements, or natural remidies they are taking? Any daily activities they find difficult, or are limited because of the above complaints? Have they ever had this problem before? If so when? Any other healthcare practitioners you are seeing? Or have seen in last 6 months, or planning to see... What are your goals for your child from a session with Eloise? (Required) Any major lifestyle changes recently? Or in the past? (Required) Please give dates Physical issues: 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 Digestive Issues: 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 Respiratory Issues: 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 Cardiovascular Issues: 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 Urinary Issues: Cystitus, difficulty or painful urinating, incontinence, kidney infections, kidney stones Nervous System Issues: Dyslexia, developmental or growth issues, epilepsy, head injuries, learning disorders, MS, muscular dystrophy, nervous disorders, numbness, tingling, poor concentration Muscule/Tissue/Bone Issues: 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 Muscles & Joint Issues: Please name any body parts which are painful. Please let me know which side L or R. Other head issues: Dental problems, speech issues, swallowing problems, dry eyes, dry mouth, eye pain or problems, headaches, migraines, nose bleeds, hearing issues, Skin Issues: Acne, eczema, psoriasis, shingles, skin conditions, soft or brittle nails Boys Only: Genital pain, problems urinating... Women Only: Nipple discharge, painful periods, heavy flow, PMS, regularity of monthly cycle. Weight gain or loss: Other: Cancer, dizziness, fibromyalgia, herpes, swollen glands, thyroid issues, tremers Pain: Mention any specific areas of pain. Giving a score of 1-10. 1: slight discomfort, 10: you need to go to the hospital Emotional & mental health: Mental Health: Mention any anxiety, depression, difficulty making plans or decisions, easily angered, obsessive tendencies Please tick any feelings which have persisted in the last few months for your child: Abused Agitated Aggravated Angry Annoyed Anxious Apprehensive Critised Depressed Despair Distress Easily irritated Fearful Grieving Guilty Helpless Hopeless Impatient Intimidated Intolerant Muddled Nervous Outraged Overwhemed Overworked Panic Paralysed Paranoid Persucuted Rejected Restless Sad Unable to grieve Uncertainty Uneasy Worried Other Any comments on feelings above? Family Stress: (Required) None Minimal Moderate Severe Work Stress: (Required) None Minimal Moderate Severe Financial Stress: (Required) None Minimal Moderate Severe Health Stress: (Required) None Minimal Moderate Severe Any comments on above stress factors? Covid: (Required) 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? Relaxation & Exercise: (Required) How much time do they have to themselves to relax? Any hobbies? Exercise? (What and how often) Sleep: (Required) How restful is their sleep? How many hours do they normally sleep? Life Goals: (Required) Anything they are excited about in life? Or for the future? Anything else? Anything else which doesn't fit on the form which feels relevant or important? Send Save draft
