This questionnaire is mainly for children below the age of 12 years since details of the mother and her state during the childís pregnancy are an important part of the  history. Please try and furnish these details as fully as possible. All information is in the strictest confidence. IF a question does not apply to you, please answer: NA

Name: 
Date of Birth:   [dd-mm-yyyy]
 
Postal Address: 
Phone No: 
E-mail Address:
 
Occupation: 
Day/Month/Year: 
 

Please describe your child in appearance including approximate weight and height


 

Describe your child's chief complaint in detail. The following are some of the relevant details required.

  1. 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?
     

  2. If possible, ask the child to explain what he/she feels about the symptom, the sensations experienced. eg: Burning, throbbing, heaviness.
     

  3. 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.
     

  4. 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.
     

  5. What circumstances preceded or were occurring around the time that the problem began to occur? Eg. Weather changes, changes at home, traveling,etc.


 
 

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.


 
What Vaccinations has you child already taken? Did you notice any unusual reactions following any of the vaccinations?

 
 

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.


 
 

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?


 

What were the major changes taking place around you with regard to your relationships, career, etc.? How did you respond to them?


 

What unusual changes in nature did you notice during your pregnancy, which you would say is unlike you otherwise?


 

iv)     What were the changes that you noticed with regard to your cravings and aversions to various food items?


 
What were the physical problems that you developed during your pregnancy? Eg. Varicose veins, acidity, backaches etc.
 

Labour and Delivery
How were your labour pains, and the progress of your labour?


 

Did you have a normal delivery? If not, why?


 

Were there any complications during or after delivery? Please give some details.


 

Did the baby cry immediately after delivery?


 
Did the midwife tell you of any other problems that were encountered during your delivery, either with you or your baby?

 
What was the approximate birth weight of the baby?

 
 

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:

 Milestones

Early 

Normal Delayed 
 Social Smile: 2- 3 months

 Holds head Steady: 3-5 months
 Teething: 7-12 months
 Rolls over from back to stomach: 7-11 months
 Raising self to sitting position: 6-9 months
 Standing by furniture: 7-12 months
 Walks with help: 10-15 months

 

Please detail if your childís 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.


 

 

Physical Generals:
How is your childís appetite?


 

Does you child seem to like particular food items and reject others?  Eg. Eggs, milk, sweet things, sour things, fruits, fish, meat, vegetables etc

 

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.


 
How thirsty does your child feel?

 

Does your child sleep well? Which position is most common during sleep?


 

Does the child feel more cold or more hot in relation to the weather? Which season seems more tolerable?

 

Mental Characteristics
These are an observation of the childís 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?


 

What is the situation at home? Eg. Family members, working  etc.   


 

What general nature does you child tend to have eg. Quiet, noisy, active, slow, etc
(It would help to compare with another sibling)


 

If your child is restless or upset, what do you have to do to calm your child?


 

What are the situations that you child is afraid of? What other fears does he have?


 

How does your child fare in school? Which are the subjects or activities he prefers?


 

How are his interpersonal relationships in school, with teachers, other children etc?


 

What other interests does your child have, which he enjoys doing? Why?


 

What are any other characteristics that you have noticed in your child? Eg. Anger, Cleanliness, Jealousy, Bullying, Violence etc


 

What does you child like to talk about all the time?


 
Have there been any incidents that have had a major impact on the child ? Please explain the incident and the childís reaction.

 
Please give some details of the family background, inter-relationships and a small description of the fatherís and motherís nature.