Child Patient Case Form

Name *

Date Of Birth

Age

Sex

Male
Female
Other

Address

Nationality

Residence Number

Mobile Number (Father)

Mobile Number (Mother)

Email (Parent/Guardian) *

Diet

Name of School

Education

Referred To Us By

What are the complaints?

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.

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)

Disease suffered from, Age, Duration

Whether you completely recovered

Medicines & treatment taken

Any other particulars

Vaccine Given, Age, Complaints After Vaccination

Duration (for how long did they last)

Any other particulars

Child's Name, Age, Sex, Diseases Suffered

Head Holding and Problems

Development History

Sitting 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?

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

Personal History

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?

How is the appetite?

Appetite & Thirst

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?

Any other

Any strong smell? Like what?

Any problem about urine?

Urination & 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?

Is there any problem regarding stools?

Stool

How much does he / she sweat?

Sweat / Perspiration - Fever - Chill

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?

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

Sleep

How is the sleep pattern?

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

Describe if anything unusual about the sleep

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

Which season does the child like?

Sensitivity to Heat & Cold

Which weather can he / she not tolerate?

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

Sexual Sphere (General)

Any history of sexual abuse?

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

Any problem in the genital organs?

What is the method you use for family planning (contraception)?

Did you suffer from any sexually transmitted disease? Syphilis? Gonorrhoea? Herpes? HIV?

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

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.

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?

Unusual attachments to whom?

Unusual desires for what?

Was the pregnancy planned, unplanned?

Mother's history during pregnancy

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?

Thirst

Any change your observed in your general pattern of

Appetite

pregnancy? name or

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?

Was it normal?

Delivery History

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)

Consent

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