Under 18 Consultation Form

Homeopathy with Cloe - Under 18 Consultation Form

PLEASE FILL IN ALL SECTIONS TRUTHFULLY AND IN DETAIL.
Under 18's Details
Name*

First NameLast Name
Birthdate*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province / County

Postal Code / Zip CodeCountry
Best phone number to contact you (Parent/Guardian). Please include your country code.*

Country CodeArea CodePhone Number
Parent / Guardian Email address*

Confirmation Email
Under 18's Email address

Confirmation Email

Presenting Condition(s)

What are the issue(s) that is being asked to treat?
Please provide, in some detail, what the issue is.
Approximately when did it start?
Are there any factors that may have contributed to the onset of the condition?
What makes it better / what helps to improve the condition?
What makes it worse?
Is there are time in the date when it is worse?
Is there are time in the date when it is better?
Are there any activities that affect the condition (swimming, hot showers, crowded spaces, before exams or a 'big event', etc...)?
Are there any other symptoms or problems you would like to discuss?
What are your favourite food(s)?
What foods do you dislike? What flavours do you dislike?
Are you thirsty often?
Are you more likely to get too hot or too cold? If so, please advise when during the day or night.
When is your 'best time' of the day? Some are 'morning people', others are 'night owls', and others don't have a 'best time'.
When is your 'worst time' of the day? These are just examples...time to get up, on the way to school, at school (during class/ during recess/ during lunch), on the bus/car back home, arriving at home, dinner-time, before bedtime.
Sleep: are there any problems with sleep? Are you a 'deep' sleeper? Do you fall asleep quickly? Do you wake up during the night?
Describe your child's personality with some general characteristics.
Please add anything else that you think may be relevant.

Under 18's current and previous medical history
Please list all CURRENT medication, vitamins and other supplements that you are taking.
Please list any long-term prescriptions that you are taking or have taken. Examples include; birth control pills, acne medication, asthma inhalers, ADHD medicines, etc
Please list all vaccinations that you have had and, if applicable, any severe reactions.
Please list all allergies and intolerance that you have or have had.
Please provide details of any other therapies that you are currently undergoing. Examples include; acupuncture, naturopathy, Chinese medicines, psychiatry, psychology, massage, other body therapies.

Under 18's medical history...continued
Please list, by date, if possible, your major diseases, illnesses, accidents, hospitalisations, medical tests.
Please list your childhood illnesess with your approximate age at the time. For example; chickenpox, tonsillitis, mumps.
Please list any life traumas that you have experienced. For example; bereavements, parent's job loss, moving, divorce, fighting in the home, witnessing trauma.

Under 18's family medical history
Information about the health of your blood relatives, whether they are still alive or have died, is of value to a Homeopathy treatment plan.

Please give details about any serious diseases, history of alcohol and/or drug addiction, epilepsy, Downs Syndrome, behaviourial problems or other conditions.

Please provide the cause of death and the age at time of death, if known.
Under 18's MOTHER'S Side of the Family
Your Mother
Your GrandMother
Your GrandFather
Your Aunts
Your Uncles
Your Cousins

Under 18's family medical history...continued
Please give details about any serious diseases, history of alcohol and/or drug addiction, epilepsy, Downs Syndrome, behaviourial problems or other conditions.

Please provide the cause of death and the age at time of death, if known.
Under 18's FATHER'S Side of the Family
Your Father
Your GrandMother
Your GrandFather
Your Aunts
Your Uncles
Your Cousins

Under 18's family medical history...continued
Please give details about any serious diseases, history of alcohol and/or drug addiction, epilepsy, Downs Syndrome, behaviourial problems or other conditions.

Please provide the cause of death and the age at time of death, if known.
Your Sisters (please provide ages)
Your Brothers (please provide ages)

I confirm that all information has been provided by me on behalf of my child/person under my care in this form is truthful and honest.
Parent/Guadian Name*

First NameLast Name
Parent/Guardian Signature*

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Homeopathy with Cloe - Under 18 Consultation Form