Child Assessment Form 1Contact Information2Basic Stats3Fitness & Exercise4Stress5Sleep6Nutrition7General Date* Year Year Year Name of Client* First Last Mother's Name* First Last Mother's Phone*Father's Name* First Last Father's Phone*Email* CLIENT INFORMATIONDate of Birth* Year Year Year Age* Height/Weight* Primary Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Have You Ever Consulted With A Psychotherapist?* Yes No Have You Ever Consulted With A Nutritionist?* Yes No Do You Have A History of Any of The Following Conditions?* Autoimmune Disorder Neurological Diagnosis Obesity Chronic Infections Learning Disability Trouble Remembering Immune Compromise ADD/ADHD Frequent Ear Infections Difficulty Focusing on Tasks Speech Difficulties Insuline Resistance None of the above Current Medications*Medication Allergies* FITNESS & EXERCISEDo You Like Physical Activity?* Yes No How Many Days A Week Do You Exercise Until You Sweat?* 0-1 2-4 5-7 What Activity Do You Prefer The Most?* Playing Outside Playing Video Games Watching TV Playing Organized Sports Are You On A Sports Team?* Yes No What Are Your Favorite Sports To Play?* STRESSAre You Happy?* Yes No Do You Feel Angry?* Occasionally Often Do You Feel Stressed Out?* Occasionally Often Do You Know How To Turn Off Your Thoughts?* Yes No Do You Know How To Relax Your Body?* Yes No How Is Your Temperment?* Stable Moody What Is Your Belief?* Life Is Difficult Life Is Easy Life Just Happens To You Do You Ever Feel Heavy or Depressed Like Eyore?* Yes No SLEEPHow Many Hours of Sleep Do Need To Feel Refreshed In The Morning?* How Many Hours of Sleep Do Get Each Night?* Do You Have Trouble Falling Asleep?* Yes No Do You Have Trouble Waking Up In The Morning?* Yes No How Do You Feel When You Wake Up?* Tired Energetic Grumpy Do You Read Before Bedtime?* Yes No NUTRITIONHave You Ever Been Told That You Have Food Allergies?* Yes No List The Allergies:*How Smart Are Your Food Choices?* Excellent more than 50% of the time Not so smart more than 50% of the time Inconsistent I do not understand what a smart choice is Do You Want To Learn More About Smart Food Choices?* Yes No How Many 8oz. Glasses of Water Do You Drink Daily?* 0-1 2-4 5-8 What Drinks Do You Consume Other Than Water?* Soda Milk Sports Drinks Juice Smoothies Plant-based Milk Alternatives None of the above List Other Drinks That You Drink:*Do You Get Stomach Aches?* Never Occasionally Frequently On Average, How Many Servings of Fruits Do You Eat Daily?* 0-2 3-4 On Average, How Many Servings of Vegetables Do You Eat Daily?* 0-2 3-4 How Many Fast Food Meals Do You Eat Per Week?* 0-1 2-3 4 or more How Many Days Per Week Do You Eat Breakfast?* 0-1 2-3 4-5 6-7 What Do You Typically Eat For Breakfast?*Do You Buy Lunch At School More Than Twice A Week?* Yes No What Do You Typically Pack For Lunch?*How Many Nights Per Week Do You Eat Dinner At Home With Your Family?* 0-1 2-3 4-5 6-7 Do You Crave Sweets?* Yes No Do You Crave Pasta?* Yes No Do You Crave Chocolate?* Yes No Do You Crave Caffeine?* Yes No Do You Eat Any of The Following Food Items Regularly? Please Check All That Apply.* Almonds Walnuts Yogurt French Fries Beef Hamburgers Flax Seeds Potato Chips Berries Salad Soy Soda Avocados Eggs Cantaloupe Beans Ice Cream Wild Salmon Milk Pork None of the above Do You Take Any Supplements?* Yes No List The Supplements You Take:* GENERALList 3 Things You Like About "You"*List 3 Things In Your Life That You Are Thankful For*If You Could Change 3 Things About Your Life, What Would They Be?*EmailThis field is for validation purposes and should be left unchanged.
