PLEASE NOTE
In order to use my time well in a busy practice, I need your intake form at least two business days prior to your appointment (unless we’ve made other arrangements.)
Kindly TYPE your answers and either email it back (if confidentiality is not a concern) or upload it to the Lydian Center website on the Forms page so it will be transmitted confidentially: http://www.lydiancenter.com/forms/index.php
Confidential Intake Form for Begabati Lennihan, r.n., c.c.h.
777 Concord Ave. Suite 301, Cambridge, MA 02138 (617) 547-8500
Homeopathic Questionnaire for Infants
(to be answered by the mother if possible)
Child’s Name
Parents’ names
Street Address
City, State, Zip
Home phone
Cell phone or other contact for primary parent contact for homeopathy (which parent?)
Cell phone or other contact number for the other parent, if you would like me to have it:
Email Address(es)
Child’s date of birth and birthweight
Age height or length weight percentiles on a growth chart (or a good guess):
What is the condition you would like to address with homeopathy? Please be as specific as possible. Give details and mention anything that makes it better or worse, including different times of day and different types of stimuli.
Has this condition existed since birth? If not, was there anything associated with the onset of the condition? Any trauma of any kind, including emotional trauma? What do you think your baby’s condition is expressing or related to (if there might be some kind of stress involved)?
What was the birth like? Any problem with delivery? Breech, induced, forceps, suction, epidural, pitocin, C-section? Please give details, and give Apgars if the birth was difficult.
Was your baby separated from you at birth for medical treatment or any other reason?
Has your baby had the standard vaccinations? More or fewer? Any reactions to vaccinations?
Has your baby been treated medically for anything? Please give details of the condition and treatment..
What was the mother’s emotional state when pregnant? Did the mother take any medications? Smoke or drink alcohol? Have changes in food cravings? Please specify.
Has your baby been particularly early or late with any developmental milestones?
Please give details.
Has your baby been breast or bottle fed? Any difficulties with feeding?
If bottle fed, with what kind of milk or formula?
Any allergic or other reactions to the milk? Is the baby weaned?
Does your baby tend to be active and restless at night?
Anything unusual about the baby’s sleeping pattern?
Please give the medical history of the blood relatives on both sides: major illnesses, causes of death, and include emotional and behavioral issues such as substance abuse, mental illness, etc.
Please say as much as you can about your baby’s personality or behavior that makes her or him different from agemates.
This form is meant for babies up to about 18 months. For 18 months to 2 or 2-1/2, please fill out this form first and also download the Child’s intake. You’ll see, it overlaps a lot. But it asks some different questions because the personality is developing more. Please review the questions on the Child’s Intake and answer any of them that elicit possibly helpful information.