Infant questionnaire

This is a free questionnaire. Fill it out and I will contact you for a consultation.

* — required fields

Personal Information

Name *

Age (in months) *

Weight *

Digestion

Sweats at night

Is there bad breath

Moles / warts / rashes / eczema

Allergies

How much water does the child drink per day (ml) *

Injuries / surgeries / head trauma / fractures

Does the child sleep well

Is often sick / has taken antibiotics

How was the birth

Did mother have severe toxicosis during pregnancy

Did mother have allergies before or during pregnancy

Did mother have constipation

Did mother take antibiotics during pregnancy

Did mother have anemia

Were there problems during pregnancy

What else should we know about the child's health *

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