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What’s your child's first name?
What’s your email address?
What’s your child's last name?
What’s your phone number?
Postal / Zip code
Street Address Line 2
Health + Medical History
Personal Health History
Please include your Diagnosis, Date of Onset, Current or Past + Description
Please include your Family Member + Illness(es)
Please include your Hospitalization/Surgeries, Date + Reason(s)
Please list any allergies or sensitivities that you have (food, environmental, etc.) + your Reactions
Was this child born vaginally or via C-section?
I'm not sure
Was this child breast-fed or formula-fed?
A mix of both
I'm not sure
Female Child: Have they started their menstrual cycle yet?
Not cycling yet
Currently on Birth Control
Female Child: have they ever taken birth control?
Have you ever taken antibiotics?
Have they had any vaccinations?
List all the supplements you're currently taking including vitamins, herbs, minerals. Please include the Brand Name, Dose + Frequency, Start Date + Reason for taking it
List all medications you're currently taking. Please include Brand Name, Dose + Frequency, Start Date + Reason for taking.
Ranking current health concerns
List your current health concerns from most important/worst and rank from 5 (most intense) to 0 (not intense). Please include how often it bothers you + how long it has been present for.