Child Patient Questionnaire - Homeopathy by CLondon

Child Patient Questionnaire

Homeopathy by C London

Childs Name

Address

DOB/Age

Relationship to patient

Parents Email (under 16)

example@example.com

Siblings, if so names & ages

PRIMARY REASON FOR SEEKING TREATMENT

(please use this as an opportunity of expressing things about your child you would rather not say in front of them. le: Fears, traits, difficulties etc. Include how the condition started and the original symptoms, then how the condition has progressed.

(If more then one condition, then list in order of priority)

When did the condition start?

Any factors that you think may have contributed to the onset of the condition?

What makes it better that you are aware of?

What makes it worse that you are aware of?

Time of day it is better or worse: (am, pm, after midnight etc.)

Any activities you find effect it?

Any other symptoms at all, even if you think unrelated, they could be relevant

MEDICAL HISTORY in full detail please:

(Tonsillitis, ear infections, asthma, skin conditions, hayfever, food allergies, courses of medications antibiotics etc.)

Was the mother or father struggling with health?

Were parents on long term medication?

Details of the pregnancy was mother put on any medication or did mother have any trauma/extra stress during pregnancy?

Cravings?

Any other changes in pregnancy?

Details of Birth describe in detail - Drugs needed by mother, any other interventions? Was conception natural or IVF? Any ailments, stresses, injuries in labour?

Breastfed or Formula fed (which milk)

Birth weight (if known)

Childhood illnesses

Vaccinations

Any reactions to medical drugs or vaccinations of any kind?

Any known allergies

Any injuries

Any other medical conditions

Do they get coldsores?

Do they get mouth ulcers?

Do they get warts?

Are they on any medication, conventional or alternative?

Developments - At what age did they crawl? At what ages did they walk? At what age did dentition start?

FAMILY HISTORY

Information about the health of your blood relatives, whether they are still alive or have died, is of value to a Homeopath. Please give details about any serious diseases, history of alcohol/drug addition, epilepsy, Down's syndrome, behavioural problems, and any unusual conditions. Please give cause of death to those who have passed & the age if known. (include - cancer, heart disease, diabetes, asthmas, additions, auto immune)

Mother & Fathers side of family

Grandmother

Grandfather

Aunts

Uncles

Brothers

Sisters

LIFESTYLE & GENERAL: only applies to children of certain ages.

What are their lifelong fav foods?

Favourite Meat?

Do they prefer Meat or fish?

Any foods or flavours they dislike? (e.g: salt, sweet, spice, vinegar)

What do they like to drink? Tea, Coffee, juices, water?

Are they a thirsty child?

GENERAL: some Questions only applies to children of certain ages.

Do they smoke? Cigarettes a day?

Are they likely to get too hot or cold?

Do they perspire? If so, where?

What is their best time of the day?

What is their worst time of the day?

Do they have any fears? (dark, spiders, heights, flying, needles, tunnels, etc.)

Any major traumatic events? (delivery, birth of sibling, moving house, moving school, injuries, parental issues?)

Please describe their sleep pattern?

Do they have problems sleeping?

Talk in sleep?

Grind teeth in sleep?

Sleep Walk?

How do they lie in sleep?

Do they have dreams/nightmares? Reoccurring? If so please explain.

Please write a detailed description of their temperament: inc things like, friendly, curious, what upsets them, how easily do they go to sleep, what disturbs their sleep, what are their fav places, how are they with strangers, how do they cope with change, how are they with pain, how are they when hungry, potty training, anything else relevant?

Anything else you wish to share.

PRE-CONCEPTION