Has the child’s mother had any occurrences of miscarriages, stillborns or abortions? Yes No If Yes, please describe.
Has the child’s mother ever had any difficulty conceiving (e.g. infertility, ectopic pregnancies): Yes No If Yes, please describe.
Did the mother smoke while pregnant? Yes
Did the mother smoke before conception? Yes No If Yes, what amount?
Did the mother use drugs or alcohol? Yes No If Yes, type and amount.
While pregnant, did the mother have any medical or emotional difficulties? (e.g. surgery, hypertension, medication) Yes No If Yes, please describe.
Did the mother travel during pregnancy? Yes No If Yes, where?
Did the mother have any infections (e.g. colds/flus/vaginal infections etc.) during pregnancy?Yes No If Yes, please
Was pregnancy easy? Difficult? Yes No If Yes, please describe.
Did breast feeding begin immediately? Type option 1 Type option 2 If Yes, please describe.
Describe any complications for the mother or the baby after the birth:Baby's Birth weight Baby’s birth length Head Circumference APGAR Scores
If Breast fed, how long? Was it difficult or easy? Easy Difficult
Approximate Feeding Schedule
If formula fed, how long? Combined with breast milk? Yes No If yes, describe
Has your child been out of the country? Where? When?
Was the process of teething difficult for your child? Yes No Please describe. Has your child been to the dentist? Yes No Any dental work done? Please describe. Describe your child’s oral hygiene practice? Is your child’s toothpaste fluoridated? Yes No
Has your child’s eyes been checked? Yes No Does your child wear glasses?Yes No Describe any vision problems: Please describe.
Frequency of stool Times per day Times per week What does the stool look like? Does your child have pain on passing stool? Have you noticed any abnormalities in your child’s stools? (colour changes, consistency, undigested foods) Please describe. Does your child experience any urinary symptoms? Please describe.
Does your child have trouble falling asleep? Yes No
Temperature of your child while sleeping is generally Hot Cold Neither If nightmares, what is the theme? What position does your child sleep in?
Who takes care of the child primarily? Does the child have a babysitter/nanny? Yes No Does the child go to daycare? Yes No How are problem behaviors, generally handled? What are the family’s favorite activities? Does your child get along with other children? Yes No Explain Does your child get along with adults? Yes No What does your child do with unstructured time? How much time does your child spend in front of the TV/Computer? What is your child’s favourite book? Does the child have a favourite toy/blanket? Yes No Describe What extra activities is your child involved in? How does your child keep his/her room? Describe neighborhood (e.g. parks, other children, safety): Describe your child’s temperament: Does she/he prefer to play alone or with others?
AngerWhat makes your child angry? Does your child get angry often/easily? Does your child experience uncontrollable rage? Does your child have difficulty expressing anger?
SadnessWhat makes your child sad? Does your child cry when sad? Does your child cry often/easily?
GriefList major experiences of grief/loss in your child’s life
FearsWhat fears does your child have?
Homeopathy is a system of medicine founded by Dr. Samuel Hahnemann (1755-1843) of Germany. It is based on the principle that “like cures like”. In practice, this means that a medicine capable of producing certain effects when taken by a healthy human being is capable of curing any illness that displays similar effects.
Another fundamental principle of Homeopathy is that it treats the patient as a whole and as an individual. There is no medicine for a particular disease. There is a medicine for the person suffering from the disease. The homeopath takes into consideration all the symptoms that distinguish a person as an individual. This includes details of the patient’s past and family history, temperament, dietary habits, sleep, etc.
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