| Name: |
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| Date of Birth: |
[dd-mm-yyyy]
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| Postal Address: |
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| Phone No: |
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| E-mail Address: |
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| Occupation: |
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| Day/Month/Year: |
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Please describe
your child in appearance including approximate weight and
height |
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Describe your
child's chief complaint in detail. The following are some of
the relevant details required.
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If this is a physical problem, which part of the
body is affected? Please specify the location.
When did this present problem begin, describe this
present episode in detail? Is this a new episode or
recurrent? If recurrent, then how often? For
how long do the symptoms last?
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If possible, ask the child to explain what he/she
feels about the symptom, the sensations experienced. eg:
Burning, throbbing, heaviness.
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What are the modalities that cause the trouble to
worsen or improve? Give details with regard to time,
temperature (hot and cold food items and drinks),
climate/weather, food items (name specific items or
tastes), applications, movement, rest, and any emotional
changes which occur.
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Add any other symptom that you find related to the
chief complaint that is not mentioned above, including how
the child feels in general while the complaint is
present.
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What circumstances preceded or were occurring
around the time that the problem began to occur? Eg.
Weather changes, changes at home, traveling,etc.
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Past
History:
Please give details of the different sicknesses the
child has suffered from since birth with approximate dates in
month or year. Also detail the treatment used for the
condition and the intensity of symptoms experienced. Anything
out of the ordinary is appreciated. |
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| What Vaccinations has you
child already taken? Did you notice any unusual reactions
following any of the vaccinations? |
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Family History:
What
are the different diseases the immediate family have suffered
from. The main emphasis should be on diseases in the history
of the mother, father, grandparents and siblings. Eg. Heart
problems, Infections, Asthma, Joint problems, Skin problems,
Cancer, etc. |
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Mother During
Pregnancy
It is important to understand the different problems
that the mother went through during her pregnancy, and in
homoeopathy we believe that the mothers emotional state has an
impact on the child she carries. Please give details that you
think may have had a strong impact on you. What was your state
of mind during your pregnancy? |
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What were the major changes
taking place around you with regard to your relationships,
career, etc.? How did you respond to them? |
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What unusual changes in
nature did you notice during your pregnancy, which you would
say is unlike you otherwise? |
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iv)
What were the changes that you noticed with regard to your
cravings and aversions to various food items? |
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| What were the physical
problems that you developed during your pregnancy? Eg.
Varicose veins, acidity, backaches etc. |
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Labour and
Delivery
How were your labour pains, and the progress of your
labour? |
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Did you have a normal
delivery? If not, why? |
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Were there any complications
during or after delivery? Please give some
details. |
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Did the baby cry immediately
after delivery? |
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| Did the midwife tell you of
any other problems that were encountered during your delivery,
either with you or your baby? |
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| What was the approximate
birth weight of the baby? |
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Milestones
(If your child is older that 3 years,
please only state what is significantly different among these
milestones. Please state EARLY/ NORMAL /DELAYED against each
of the following milestones).
The normal milestones that a
child goes through are:
Please detail if your
child’s milestones are significantly different. It would also
help to compare the milestones with another sibling. Also any
other related symptoms the child experienced in relation to
the milestones, like teething, walking etc. |
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Physical Generals:
How is your child’s
appetite? |
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Does you child seem to like
particular food items and reject others? Eg. Eggs, milk,
sweet things, sour things, fruits, fish, meat, vegetables
etc |
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How much does your child
perspire? Which part of the body does he/she perspire more?
Eg: head, face (forehead, around mouth), palms, soles, neck
etc.
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| How thirsty does your child
feel? |
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Does your child sleep well?
Which position is most common during sleep? |
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Does the child feel
more cold or more hot in relation to the weather? Which
season seems more tolerable? |
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Mental Characteristics
These are an observation of the
child’s behaviour in different situations. The questions below
are to help you notice these characteristics. Please add more
information if you find it relevant.
How many siblings does
the child have, and what is his/her position among
them? |
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What is the situation at
home? Eg. Family members, working etc.
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What general nature does you
child tend to have eg. Quiet, noisy, active, slow, etc
(It
would help to compare with another sibling) |
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If your child is restless or
upset, what do you have to do to calm your
child? |
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What are the situations that
you child is afraid of? What other fears does he
have? |
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How does your child fare in
school? Which are the subjects or activities he
prefers? |
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How are his interpersonal
relationships in school, with teachers, other children
etc? |
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What other interests does
your child have, which he enjoys doing? Why? |
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What are any other
characteristics that you have noticed in your child? Eg.
Anger, Cleanliness, Jealousy, Bullying, Violence
etc |
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What does you child like to
talk about all the time? |
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| Have there been any
incidents that have had a major impact on the child ? Please
explain the incident and the child’s reaction. |
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| Please give some details of
the family background, inter-relationships and a small
description of the father’s and mother’s nature. |
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