Child Assessment Form 1 Contact Information2 Basic Stats3 Fitness & Exercise4 Stress5 Sleep6 Nutrition7 General Date* MM DD YYYY 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* MM DD YYYY Age*Height/Weight*Primary Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Have You Ever Consulted With A Psychotherapist?*YesNoHave You Ever Consulted With A Nutritionist?*YesNoDo 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?*YesNoHow Many Days A Week Do You Exercise Until You Sweat?*0-12-45-7What Activity Do You Prefer The Most?*Playing OutsidePlaying Video GamesWatching TVPlaying Organized SportsAre You On A Sports Team?*YesNoWhat Are Your Favorite Sports To Play?* STRESSAre You Happy?*YesNoDo You Feel Angry?*OccasionallyOftenDo You Feel Stressed Out?*OccasionallyOftenDo You Know How To Turn Off Your Thoughts?*YesNoDo You Know How To Relax Your Body?*YesNoHow Is Your Temperment?*StableMoodyWhat Is Your Belief?*Life Is DifficultLife Is EasyLife Just Happens To YouDo You Ever Feel Heavy or Depressed Like Eyore?*YesNo 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?*YesNoDo You Have Trouble Waking Up In The Morning?*YesNoHow Do You Feel When You Wake Up?*TiredEnergeticGrumpyDo You Read Before Bedtime?*YesNo NUTRITIONHave You Ever Been Told That You Have Food Allergies?*YesNoList The Allergies:*How Smart Are Your Food Choices?*Excellent more than 50% of the timeNot so smart more than 50% of the timeInconsistentI do not understand what a smart choice isDo You Want To Learn More About Smart Food Choices?*YesNoHow Many 8oz. Glasses of Water Do You Drink Daily?*0-12-45-8What 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?*NeverOccasionallyFrequentlyOn Average, How Many Servings of Fruits Do You Eat Daily?*0-23-4On Average, How Many Servings of Vegetables Do You Eat Daily?*0-23-4How Many Fast Food Meals Do You Eat Per Week?*0-12-34 or moreHow Many Days Per Week Do You Eat Breakfast?*0-12-34-56-7What Do You Typically Eat For Breakfast?*Do You Buy Lunch At School More Than Twice A Week?*YesNoWhat Do You Typically Pack For Lunch?*How Many Nights Per Week Do You Eat Dinner At Home With Your Family?*0-12-34-56-7Do You Crave Sweets?*YesNoDo You Crave Pasta?*YesNoDo You Crave Chocolate?*YesNoDo You Crave Caffeine?*YesNoDo 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?*YesNoList 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.
