Child Neurotransmitter & Nutrition Questionnaire | RedRiver Health And Wellness Center

CONDITIONS WE MANAGE
Our Team
- Providers
- Staff
Free Guides
Media
- Testimonials
- Live Broadcasts
Featured Articles
Locations
- Albuquerque
- Boise
- Las Vegas
- Springville
- South Jordan
- St. George
- Logan
- Farmington

CONDITIONS WE MANAGE
Our Team
- Providers
- Staff
Free Guides
Media
- Testimonials
- Live Broadcasts
Featured Articles
Locations
- Albuquerque
- Boise
- Las Vegas
- Springville
- South Jordan
- St. George
- Logan
- Farmington

REQUEST A CONSULTATION

REQUEST A CONSULTATION

CONDITIONS WE MANAGE
Our Team
- Providers
- Staff
Free Guides
Media
- Testimonials
- Live Broadcasts
Featured Articles
Locations
- Albuquerque
- Boise
- Las Vegas
- Springville
- South Jordan
- St. George
- Logan
- Farmington

Email address

Name

Age

Sex

Date

SECTION: GENERAL

Does your child have any food sensitivities or allergies? (please list)

List your child’s 4 healthiest foods eaten regularly.

List your child’s 4 unhealthiest foods eaten regularly.

How many times a week does your child eat candy?

How many times a week does your child drink soda pop?

Please list the top 4 foods your child craves regularly?

List the medication(s) your child is currently prescribed and over the counter.

Do you find it difficult as a parent to have your child on a special diet?

SECTION: A (K52)

Does your child eat pasta, breads, and breaded foods?

0 1 2 3

Does your child have symptoms (fatigue, hyperactivity, etc.) after eating wheat foods?

0 1 2 3

Does your child eat dairy products?

0 1 2 3

Does your child have symptoms (fatigue, hyperactivity, etc.) after eating dairy products?

0 1 2 3

SECTION: B (K53)

Does your child eat fried fish?

0 1 2 3

Does your child eat roasted nuts or seeds?

0 1 2 3

Is your child missing essential fatty acid rich foods in his/her diet? (for example: avocadoes, flax seeds, olives) (mark “0” if present, “3” if missing)

0 1 2 3

Does your child eat fried foods?

0 1 2 3

SECTION: C (K34)

Is your child’s mental speed slow?

0 1 2 3

Does your child have difficulty with learning or memory?

0 1 2 3

Does your child have difficulty with balance and coordination?

0 1 2 3

SECTION: D (K16)

Does your child have stress?

0 1 2 3

Does your child not have enough sleep and rest? (mark “3” if not enough)

0 1 2 3

Does your child not have regular exercise? (mark “3” if no exercise)

0 1 2 3

Does your child feel overly worried and scared?

0 1 2 3

SECTION: E (K16, K51)

Does your child have temper tantrums?

0 1 2 3

Does your child exhibit wild behavior?

0 1 2 3

Does your child frequently yell or scream for unnecessary reasons?

0 1 2 3

Does your child have an inability to nap or sleep when physically exhausted? (mark “3” if unable)

0 1 2 3

Is your child overly talkative?

0 1 2 3

Does your child fidget and squirm when seated?

0 1 2 3

Does your child run and climb excessively when it is inappropriate?

0 1 2 3

Does your child have difficulty playing quietly or engaging in leisure activities?

0 1 2 3

SECTION: F (K51)

Does your child get excited easily?

0 1 2 3

Does your child have anxiousness and panic for minor reasons?

0 1 2 3

Does your child feel overwhelmed for minor reasons?

0 1 2 3

Does your child find it difficult to relax when she/he is awake?

0 1 2 3

Does your child have disorganized attention?

0 1 2 3

SECTION: G (K50)

Does your child seem depressed?

0 1 2 3

Does your child have mood changes with overcast weather?

0 1 2 3

Does your child have symptoms of inner rage?

0 1 2 3

Does your child seem uninterested in games or hobbies?

0 1 2 3

Does your child have difficulty falling into deep restful sleep?

0 1 2 3

Does your child seem uninterested in friendships?

0 1 2 3

Does your child have symptoms of unprovoked anger?

0 1 2 3

Does your child seem uninterested in eating?

0 1 2 3

SECTION: H (K49)

Does your child have difficulty handling stress?

0 1 2 3

Does your child have anger and aggression while being challenged?

0 1 2 3

Does your child feel tired even after long sleeps?

0 1 2 3

Does your child tend to isolate from others?

0 1 2 3

Does your child get distracted easily?

0 1 2 3

Does your child have constant need and desire for candy and sugar?

0 1 2 3

Does your child have disorganized attention?

0 1 2 3

SECTION: I (K48)

Does your child have difficulty with visual memory?

0 1 2 3

Does your child have difficulty remembering locations?

0 1 2 3

Does your child have fatigue or low endurance for learning activities?

0 1 2 3

Does your child have difficulty with attention or low attention span or endurance?

0 1 2 3

Does your child have slow or difficult speech?

0 1 2 3

Does your child have uncoordinated or slow movement?

0 1 2 3

Request a Consultation

All Locations Currently Offering Telehealth Appointments.
We are pleased to offer consultations to new patients. A half-hour consultation is $100.

To request an appointment please complete the form below

Name (required)*
Email Address (required)*
Phone*
Country (required)*
Country

Locations (required)*
How did you hear about us?*
Message (required)*

Phone
This field is for validation purposes and should be left unchanged.

Therapies
About Us
Our Team
Videos
Contact
Our Blog

Copyright © 2020 Red River Health and Wellness Center
All Rights Reserves
Privacy Policy
Terms & Conditions
Sitemap
Website built by SEO Werkz

Download your free brochures that will inform you about Low Thyroid and autoimmune conditions.