Child Consult

First Name * Last Name * Email *   Address * Address *AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Phone Number Date of Birth * Age * Height Weight What is your goal for this consultation? * The type and duration of the seizures What are the frequency of the seizures? How long have they had seizures? What medications is your child currently on? Has your child ever tried a diet as a treatment for seizures? If so which one? Why are you looking into the MAD? Has your doctor suggested it? Are you already consulting a dietician? Are there any other serious illnesses/hospitalizations/injuries that are relevant? Does your child have any allergies or sensitivities? Please list: Are you involved with any other therapies? Please list: Does your child take any supplements? Please list: Will friends & family be supportive of a diet/lifestyle change? What are your childs favorite foods? What percentage of your food do you cook at home? What are your child's current eating habits? Breakfast, Lunch & Dinner Is there anything else you would like to share?   Submit