Children’s Homeopathic Intake Form Child’s NameParentsStreet AddressCityState/ProvinceZIP / Postal CodePhone (best)Email AddressParents’ Marital StatusDate of BirthAgeBirthweight (if known)Current weight1. What is the child’s chief complaint (CC)?2. When did this problem begin? What happened in the child’s life around that time? What do you think caused it?3. What aggravates the CC (certain types of foods or weather, movement, light, noise, heat/cold, being at the seashore, or anything else that you can think of)?4. At what time of the day or night is the CC the worst? Specify an hour if you can.5. What symptoms can you identify that accompany the CC?6. Does your child have any physical aches or pains (stomach, earache, etc.)?7. Does your child prefer to be alone or play with other children?8. What is his or her energy level (high or low)?9. Is he or she fidgety?10. Is your child oversensitive to noise?11. Does your child have trouble concentrating?12. How did the child react to these situations? Please try to think of mental and emotional reactions as well as any physical symptoms that may have developedVaccinationsBirth of younger siblingSpending the night with a friendTraveling with the familyFirst day at schoolGoing away to camp etc. without the family13. How many rounds of antibiotics has the child had and for what?14. Any skin conditions treated with cortisone cream?15. Did the child suffer from a childhood disease with very severe symptoms? (measles, chickenpox, German measles, croup, mumps, etc.)16. When ill or upset, does the child tend to cling to you or want to be left alone?17. What is the child’s behavior in playing with other children? Does it make a difference if the other kids are younger or older?18. What feedback do you get from the child’s teachers about behavior in class?19. Do you have pets, and what is your child’s attitude towards them?20. a) What types of food does your child crave? Please be as specific as possible and list as many as you can.21. b) What types of food does he/she refuse to eat?22. c) What types of food does your child react badly to, whether physically (bloating, diarrhea, etc.) or behaviorally, and what are the reactions?23. Any fears that are unusual for a child of your child’s age (of the dark, being alone, lightning, thunder, etc.)? Are there nightmares?24. Is the child chilly or hot?25. Is there excessive perspiration on the head and/or feet?26. Is the child very affectionate when not sick?27. Is the child unusually sympathetic (showing concern for the suffering of other children, animals, etc.)?28. Does the child like music? What kind? Like dancing? Do symptoms (like restlessness) improve with music?29. Is the child obstinate? How is this expressed?30. Is the child fastidious (neat and orderly)?31. Is the child sensitive to criticism and reprimand?32. Can you think of any unusual or distinctive things about your child – behavior, fears, fantasies, desires, attachments, preferences in clothing, etc.?33. Give a timeline for the child with all possible traumas, diseases, important events, deaths in the family. Describe the reaction of your child towards these events.Send Message
