Rocky Mountain Natural Health Clinic

Kids Questionnaire - for kids under 9 years old

First Name
Last Name
Date of birth?
Parents Names?
What are your child's health concerns?
Describe mother's pregnancy
Any problems with labor or delivery?
Was you child born by C-Section
Were suction or forceps used during delivery?
Did mother have ANY drugs during pregnancy?
Did child have anti-biotics in first two years?
Did child have routine vaccination schedule?
How were 1st 2 years of health?
Did/Does your child nurse?
how long did your child nurse exclusively?
How often does you child nurse?
What were 1st foods?
What is a typical breakfast?
What is a typical Lunch?
What is a typical dinner?
Does you child snack? on what?
Does your child eat desserts? what kind?
How much water?
How much juice?
How much milk?
How much pop?
Any other drinks?
How often does your child poop and pee?
What color is the poop?
What time does your child go to sleep?
Does your child have night-mares?
Does your child sleep through the night?
Does you child nap? for how long?
Where was your child born?
Does your child have any allergies?
How often does your child catch a cold?
Is you child taking any prescription drugs? please list:
Is your child taking any supplements? please list:
How would you describe your childs emotions?
Is your child having any difficulties in school?
What does your child do for fun? Exercise?

Treating The Whole Person