Name

Date Of Birth

Age

SexMaleFemale

Address

Nationality

Residence Number

Mobile Number (Father)

Mobile Number (Mother)

Email (Parent/Guardian)

DietVegetarianNon-VegetarianEgg-Vegetarian

Name Of School

Education

Referred To Us By

Details Of Present Illness

In Homeopathy, prescription is based on precise details of various complaints that the child has, mere mention of a complaint does not suffice for a good prescription. Please follow the instructions given below for helping us understand your child’s complaints. We require the following details about your child’s symptom.

What are the complaints?

Since when is the child having these complaints?

Sensation

Origin of cause

Location : Please give the exact location of sensation, pain or eruption. Also describe where the pain or sensation spreads

What are the factors that influence your child’s health? e.g. Weather, food, pressure, anxiety etc. or any other (please refer to part 4 on page 16 and 17 for a detailed list of the factors) Please mention how each factor affects the child’s whether it increases or decreases his/ her complaint, and also how much does in affect child’s complaint. (e.g. headche worse by even little exposure to sun, heachache better by pressing the head)

Part & Family HistoryTyphoidCholeraFood poisoning WormsDiarrhoea DysenteryMeaslesGerman MeaslesChicken-pox SmallpoxMumpsWhooping coughMalaria JaundiceAny Liver SpleenGall bladder diseaseMiscarriageAbortionCurrettingsSickness during PregnancyProlapse of uterusMalnutrition RicketsRheumatism BackacheSyphillisGonorrhoeaHeart troubleBlood pressureGiddinessNephritis (Kidney or Urine trouble)DiabetesProstate troubleTonsils operationAbdomen operationAppendix operationHernia operationPiles operationRenal stones operationGall stones operationPhimosis operationHydocele operationCataract operationDiptheriaSeptic TonsilsAdenoids RecurrentSinusitisBronchitis-EosinophiliaColdFeverChillPneumoniaAsthmaPleurisyT. B.Any serious shockGriefDisappointmentsFrightMental upsetDepressionNervous break downChronic headachesNumbnessCrampsFitsConvulsionsPolioParalysisMeningtis - Any lumbar puncture doneAny major accident or injury to body or headAny occasion of unconsciousnessAny major bleeding from any part of the bodyPimplesBoilsCarbunclesRingwormsFungusScabiesEczemaHerpesUrticariaAlleryUlcers on any part of the body

Disease suffered from, Age, Duration

Whether you completely recovered

Medicines & treatment taken

Any other particulars

Vaccination History

Vaccine Given, Age, Complaints After Vaccination

Duration (for how long did they last)

Any other particulars

Family History

List of Major DiseasesAnaemiaCancerDiabetesInsanityRheumatismT.B.PleurisyLeprosyEpliepsyFitsBleeding tendencyUrticariaEczemaAsthmaParalysisHypertensionHeart troubleKidney diseasesLiver diseases

Information About Child's Siblings

Child's Name, Age, Sex, Diseases Suffered

Development History

At what age did the child start

Head Holding and Problems

Sitting and Problems

Standing and Problems

Walking with support and Problems

Walking without support and Problems

Teething and Problems

Speaking and Problems

Urine Control and Problems

Were there any problems in the growth & development of the child?

Personal History

Does the child suffer from any allergic conditions ? If yes, please specify

Also mention the items that you feel the child is allergic to

If any specific allergic testing is done, then please mention and attach your investigation reports

What substances is / was the child addicted to like internet, games, shopping, any drug substances. Is the child habituated to TV, games, internet, shopping or any other?

Appetite & Thirst

How is the appetite?

When is the child most hungry?

What happens if he / she have to remain hungry for long?

How easily does he /she feel full after eating? (e.g. soon / eating a lot etc.)

Does he / She have a habit of eating fast?

How much thirst does the child have?

How frequently does he / she drink and how much?

Any particular time that he /she especially thirsty?

Does he / she crave for cold / warm water / ice?

Salty FoodLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Bitter ExtraLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Spicy FoodLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Sour FoodLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Sweet FoodLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Exotic FoodLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

BreadLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

ButterLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Fatty Food / Fried FoodLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

CabbageLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

OnionLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

TeaLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

CoffeeLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

MilkLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

CurdsLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

ButtermilkLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

FruitsLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Warm FoodLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Cold FoodLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

IceLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Ice-creamLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Cakes / PastryLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

ChocolateLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

CheeseLikeDislikeStrongly DislikeDisagreesStrongly Disagrees

Any other

Any strong smell? Like what?

Urination & Urine

Any problem about urine?

Any difficulty about the flow? Slow to start, interrupted, feeble, dribbling etc.?

Any involuntarily urination? When?

Do you have any trouble before, during and after passing urine?

Stool

Is there any problem regarding stools?

Sweat / Perspiration - Fever - Chill

How much does he / she sweat?

On what part does he / she sweat the most?

Does the sweat smell? What is the kind of smell?

Does the sweat stain his clothes? What colour?

Is there perspiration on the palms or soles?

Sleep

Describe what the posture is during sleep? (E.g. on back, abdomen, sides)

How is the sleep pattern?

Is the child able to sleep in any position? In which position is he / she uncomfortable?

During sleep does the childGrind teethDribble salivaSweatKeep eyes or mouth openWalkTalkMoanWeepBecome restlessWake up with a jerk

Describe if anything unusual about the sleep

How much does he / she cover/uncover any parts?

Check types of dreams that the child hasAnimalsWild animalsThievesGhostsFlyingHousesWaterDead bodiesSuicideDrinkingLightningAccidentsWarsDancingMoneyVomitingBlood-bleedingSexual PleasurePainMutilationsTempleFailure / ExamsBeing unpreparedVexationInsultsCrimePoisonDangerChildrenMarriageRecentsPhysical ExertionColouredCats - DogsSnakesAnxiousTravellingSwimmingFruitsSnowDead personsBeing HungryEatingStormFallingTalkingPleasantDay’s workPassing stoolExcrements / soilingRapeIllnessPrayingChurchUnsuccesful efforts? For what?GriefQuarrelsPoliceMurderMisfortunesBeing pursuedPartiesOf eventsFutureMental ExertionMulti-ColouredHorseRobbersFearfulRidingDrowningTreesDeath, Whose?Part of BodyBeing ThirstyFireRainShootingSingingBusinessForgotten workUrinatingRomanticNakednessSicknessReligiousGodMissing TrainWeepingJealousyImprisonmentKillingInsecurityOf peopleFeastsRemotePropheticFatigue

Sensitivity to Heat & Cold

Which season does the child like?

Which weather can he / she not tolerate?

Sexual Sphere (General)

Does the child masturbate? What is the frequency? What is its effect?

Any history of sexual abuse?

Did the child ever suffer from any infection of the genital organs?

Any problem in the genital organs?

Mind

In order to understand you we will be asking certain questions. Answer them freely, carefully and completely. This information will help us much in giving you the correct remedy. Also such a remedy will help improve your mental make up. Answer freely. Answer frankly. Answer completely.

What is the effect of main complaint and associated complaints on the child?

Describe the unusual sensation they experience during stressful situations like nightmares, fears, before exam, with the incident

What are his / her fears (existing and / or imaginary)?

Any incident which had a deep impact on him / her ? Describe in detail

What are the stories / fairytales that he / she likes to read / listen to?

What are his / her imaginations / fantasies? Describe in detail

What dream does the child gets or had?

What are the nightmares that he / she gets?

What are his / her interests and hobbies?

Describe about the specific toys, games / specific TV serials, cartoon characters, movies the child likes

How is he / she at sports and other activities?

Describe about the drawing and coloring he / she likes

What are the other activities the child likes to?

Describe all the qualities of your child, which makes him / her different from other children, which is unique to him / her

What does he / she wants to become when he is grown up and why? What are his / her ambitions?

Whom does he / she idealize (and why?). What is about him that he /she admires the most?

How his / her behavior with parents, teachers, friends relatives? What are the qualities he / she admires in them?

How his/her behavior in school and what is his / her teacher’s opinion about the child?

What kind of questions does him/ she asks to his / her parents, relatives and teachers?

What are his / her views about the city, state, country and world?

What makes the child cry or laugh?

What makes your child very angry and irritable?

What does the child do when he /she is alone?

What are your child’s five wishes?

Tick the qualities that your child or you as child hadObstinacyUnusual fearsTemper tantrumsShynessDisobedienceUnusual attachmentsAggressionHyperactivityBiting nailsDestructivenessThumb-suckingCouragePossessivenessCompetition - winning spiritPicking and playing with shawls, handkerchievesPicking and playing with mother’s body partsPicking and playing with anything elseSlibling jealousyAny special skillsReligiousUnusual desiresDullness of memoryBoastingSlownessStealingLaziness / IndolenceTelling liesSensitive / Emotional

Unusual attachments to whom?

Unusual desires for what?

Mother's history during pregnancy

Was the pregnancy planned, unplanned?

Describe the circumstances around the period of conception? (Stressful if any)

Dreams during your pregnancy including around the time of conception

What changes you have observed within you?

Tell the changes you noticed in your nature and behavior from the time you conceived till you delivered the child

Anything unusual or particular phenomena you observed only during pregnancy that you think were not a part of your routine nature and that occurred with the pregnancy?

Any incident during pregnancy that had a deep impact on you? Describe your feelings, thoughts or any sensation associated with it

What were your dreams during pregnancy? Did you have any unusual, recurrent dream that had a deep impact on you ?

What were the thoughts, fantasies and imaginations about your child during pregnancy?

Did you have any unusual thoughts during that period? Describe in detail. What was your reaction to that?

Did you experience any unusual bodily sensation / movement during this period? Describe the whole experience

Did you have any fear or nightmares during this period? Describe it

Was there any changes in your interests and hobbies during pregnancy?

Did you observe any change in your relationship with people during this period? What was it?

What was the changes in the likes / dislikes for any particular food?

Was there any changes in your sensitivity to heat / cold during pregnancy?

Any change your observed in your general pattern of

Thirst

Appetite

Perspiration

Sleep

Bowel movements

Urination

Sexual desire

Any addiction during pregnancy?

Were you on / any medication during pregnancy?

Did you suffer from any disease during pregnancy?

Delivery History

Was it normal?

Was the delivery full term / early / delayed?

Was it Caesarian section / forceps / vacuum delivery? Any other procedure done?

Please mention if your child has taken any Homoeopathic Medicine. Brief us with the name of the medicine he / she has received along with his / her response to the same. (If you are aware of)

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