Jan ClareDipHom

Classical Homeopath

gisbornehomeopathy.net

ph (027) 4488 962

Please email the completed questionnaire

Child’s Health Questionnaire
Patient’s name:
Address:
Date of birth:
Age(s) of siblings:
Parent’s name/s:
Home phone number:
Mobile/s:
What would you like homeopathic treatment for? Please describe your child’ssymptoms:
When did this problem start? (include any events that preceded it e.g. starting pre-school orschool, moving house, severe illness, etc)
Are there any factors that make your child’s symptoms better (e.g. rest, activity, warmth, cold, company, being alone, time of day, season etc):
Are there any factors that make your child’s symptoms worse (e.g. rest, activity, warmth, cold, company, being alone, time of day, season, etc):
Have you consulted your doctor about this problem? If so, how many visits have you had?
Family doctor’s name and contact details:
Has your child previously had homeopathic treatment for this problem? If so please list remedies used (if known):
Please list all medicines or supplements/remedies currently being used:
Any additional health concerns?
Child’s medical history
Mother’s health during pregnancy:
Length of labour:
Interventions/medications during birth:
Child’s birth weight:
Apgar scores:
Breastfed? If yes, for how long?
Milestones: has your child had delayed or very early development in any area (e.g. teething, talking, walking, puberty, etc)? If yes, please describe:
Please indicate with * if your child has ever had:
Asthma Bedwetting Bronchitis Chickenpox Cold-sores Croup Ear infections Eczema Frequent colds Glandular fever Hay-fever Impetigo Influenza Measles Mumps Nappy rash Seizures Teething problems Tonsillitis Warts
Whooping cough Worms
Has your child ever been hospitalised? If yes, please describe the illness or operation(s):
Family medical history
Please indicate with * if any close family members have the following conditions:
Alcoholism or substance abuse Allergies Arthritis Asthma Cancer Depression Diabetes Ear, nose or throat problems Eczema Epilepsy Heart attack Hypertension Pneumonia Psoriasis Stroke Tuberculosis
Allergies/Sensitivities
Allergy to food(s):
Allergy to medicine(s):
Reactions to environmental factors (earthquakes, sunlight, pollen, dust mite, etc):
Reactions to immunisations:
Reactions to the weather e.g. strong wind, thunderstorms:
Reactions to being told off/reprimanded:
Any other sensitivities? (e.g. to loud noise, crowds, strangers):
Body temperature and perspiration
Is your child’s body temperature average, warmer or colder than usual?
How does your child react to the cold?
How does your child react to the heat?
Where do you notice perspiration on your child?
Appetite
How is your child’s appetite:
Any strong cravings or food preferences?
Any strong aversions to certain foods?
Any foods that upset him/her?
How thirsty is your child?
Please list what your child eats in a normal day:
Breakfast:
Lunch:
Dinner:
Snacks:
Drinks:
Digestion
Please indicate if your child has any of the following:
-excess wind
-tummy pains
-bloating
-loose bowel motions
-difficult bowel motions
-any other digestive problems?
How often does your child have a bowel motion?
Any problems with urination?
Sleep
Please indicate if your child has any of the following:
-difficulties falling asleep:
-frequent waking:
-nightmares:
-restless sleep:
-sleep-walking:
-snoring:
-teeth-grinding:
-any other sleep problems?
What position does your child usually sleep in?
Personality and temperament
Please describe your child’s usual temperament:
How is your child’s temperament when he or she is unwell?
Please describe your child’s energy levels:
Hobbies and interests:
Please describe any fears or phobias:
Please describe any emotional or behavioural issues your child may be experiencing:
Is there anything else you’d like to mention about your child?

Thankyou for completing this questionnaire

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