Children's Consultation

Surname

Given Name/s*

Full Address*

Parent Contact No*

Parent Email Address*

DOB of Child/Youth

Weight

Height*

Racial Group/Ethnicity

What are your concerns you seek professional guidance for (please detail)?

When did YOU 1st notice this hair loss/scalp problem (Age Yearor Month)?

Did it begin: suddenly OR noticed slowly over time? (Please indicate which)

Have you observed (or your child reporting) any scalp concerns:

red, inflamed appearance of scalp

flaking, scaling scalp which is either white/grey or yellow in colour

itching scalp

Other observations noted:

Have you observed (or your child reporting) any changes in the hair

noticeably dry hair or scalp

a greasy/oily scalp/hair OR:

greasy oily scalp but with dry/brittle hair

hair breakage

hair is not growing

Is there a history of hair/scalp problems with siblings or 1st cousins (please detail)

Have you previously tried to do something about this problem?

Yes

If "Yes" what?

IF your child’s hair shed suddenly in increasingly excessive amounts, can you recall any of the following 1-3 months prior to this problem developing

illness where high temperature/fever or rash involved

underwent surgical/medical procedure involving anaesthetic or blood loss or post-operative infection

Vaccinations/injections blood or other transfusions IVantibiotics(please detail)

Commence or cease any prescribed medication within the last 3 months? If “YES” what medication?

Exposed to severe intense or prolonged stress (family break-up death of someone close – including pets; known bullying or ostracization at school or online etc.)

Does your child have any current OR chronic health problems OR have persistent Colds OR Sinus problems OR Ear infections OR Tonsillitis – OR other? If “YES” please detail*

Does your child regularlytake prescribed (or non-prescribed) medication or supplements? If “YES” please detail*

Do they have any known allergies or sensitivities? If “YES” please detail*

Please detail an average daily diet for your child

Breakfast*

Lunch*

Dinner*

Snacks (how often do they seek snacks?)*

Do they constantly ‘seek’ sugary/refined foods or drinks? NO/YES - What?

What foods DON’T they like (or tend to avoid)?

What Fluids do they consume on an average day, & how many of each? (please indicate which & indicate amount per day)

Water

Juices

Cola/Energy or Sugary

Drinks Coffee/Tea

How would you describe your child’s emotions

easy-going/carefree

stresses easily

tense/worrisome/anxious

Please indicate which mood you feel is most predominant

In what areas do you feel these emotions predominate?

Home/Family environment

School or other social areas

Generally

Do you feel your child has any age INAPPROPRIATE issues?

Bedwetting /’soiling’ their underwear with urine or faeces when you know they are toilet-trained?

Temper ‘tantrums’ Separation ‘anxieties’

Cries or is easily distressed over trivial matters

Teeth-grinding when asleep

How would you describe their energy levels?

High energy wakes tired or irritable with tired slump in afternoon but appears to get a ‘2nd wind’ of energy in evening (6pm onwards)

easily tires or fatigues

noticeably tired or listless after consuming wheat-derived or other foods (pasta, bread, cereals, or milk)

Does your child complain of OR do you observe?

'bloated’ distended stomach, excessive ‘flatulence’, burping or hiccupping

complaints stomach pains

persistent ‘bad breath’ (termed halitosis which may indicate Gut dysbiosis or the need for better mouth hygiene including flossing). Does their breath have a ‘garbage ormetallic’ (acetone) odor to it?

they experience diarrhoea generally or particularly after eating or ongoing constipation issues

where appropriate, do your child’s stools look ‘normal to you (please detail)

Details

What daily or weekly exercise/sport does your child do? (please detail what/hours or times per week):

Does your child regularly experience disturbed sleep OR persistent ‘bad dreams’ OR teeth ‘grinding’? YES/NO If“YES” why do you think this occurs? (Please detail)

How often do you/they wash their hair?

Daily

‘couple of times’ per week

less than weekly

What shampoo/conditioning or other grooming products do you use (Brands)?

Physical Assessment (Please SELF-ASSESS your Child – as below: eyes nails tongue + skin/scalp if applicable)

Eyes

Eyes appear normal with no irritation observed pale conjunctiva (inside bottom eyelid)

Yes

Blepharitis (red/irritated eyelids)

Yes

Lost or sparse eyebrows or loss of eyelashes

Yes

Nails

Nails appear normal with no abnormalities observed

Yes

Thin soft or brittle that chip flake or split easily

Yes

Compromised nail or skin integrity around the nails (biting nails or other causes)

Yes

‘White spotting’ on nails

Yes

(Please note how many/ size; are they feint or bright in colour)

Tongue

Tongue appears normal with no abnormalities observed

Yes

‘Mapped’ (deep lines or cracks in tongue);

Yes

‘Lumpy’

Yes

Spotted

Yes

Coated – (mustard/yellow OR grey/white)

Yes

‘Scalloping’ around sides of tongue

Yes

‘Beefy’ red in appearance or red at tip of tongue

Yes

Child reports the tongue OR the tip of the tongue is sore or sensitive tongue appears greasy or slimy or pale ‘white’ tongue or other unhealthy tongue appearance.

Yes

Additional Information (OR other changes observed):

Thank you for your time and patience in completing this questionnaire. When you have submitted this consultation you will be automatically taken to a secure payment form.

Physical Assessment (Please SELF-ASSESS your Child – as below: eyes nails tongue + skin/scalp if applicable)

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