Intake form · homeopathy, children

Personal details

Full name

Email address

Personal information

Age

Date of birth

Does the child have any diagnosis, medical or psychological condition?

If yes, what diagnosis?

Reason for the consultation, and history

What are the symptoms or problems you are seeking a homeopathic consultation for? (Describe the symptoms in detail, when and how they appear, and anything that influences them.)

When did the symptoms begin? Do they connect with any particular event or period?

What other health problems does the child have? The history of illness, in as much detail as possible. You can attach medical documents if needed.

What health problems do the parents, siblings or other blood relatives have?

What is the atmosphere like at nursery or school? Have there been conflicts or other unusually demanding situations?

How is the relationship with the parents and with brothers or sisters? How is the relationship between the parents, what is the atmosphere at home, and have there been conflicts or other demanding situations?

Weight, height, hair and eye colour

For girls: what are the periods like? Frequency, length, anything particular about the flow, how she feels during them, and the age of the first period.

How is the child right now, today: symptoms, sensations, anything particular, any detail?

Anything else you consider relevant

Does the child have depression, or has the child been diagnosed with depression?

On a scale from 1 to 10, where 1 is the mildest depression and 10 the worst you can imagine, which number would you say it is?

Does the child have anxiety, or has the child been diagnosed with anxiety?

On a scale from 1 to 10, where 1 is the mildest anxiety and 10 the worst you can imagine, which number would you say it is?

What makes the child anxious?

Does the child have fears? If yes, what are they?

Does the child feel anger or rage? If yes, what makes the child angry?

On a scale from 1 to 10, where 1 is the mildest anger and 10 the strongest you can imagine, which number would you say it reaches?

How well does the child sleep at night?

How many hours a night does the child sleep at the moment, on average?

Does the child usually fall asleep easily, or not?

Does the child usually wake during the night?

How many times?

Lately, would you say the child sleeps deeply, moderately, or very lightly?

What are the child's dreams like? Would you say they are usually pleasant, or unpleasant, with fears or even nightmares?

Has the child ever had, or does the child have, sleepwalking?

Has the child ever had sleep paralysis?

Would you say the child usually wakes up rested and energetic, or still rather tired?

What would you say about the way the child eats? Are there foods the child prefers, and foods the child never eats at all?

Is the child taking any medication?

If yes, which ones and what for?

Has the child had traumatic experiences? If yes, please list the kind of trauma (physical, emotional, sexual, and so on).

Preference for warmth or cool, for being alone or in company

What are the bowel movements like (consistency, colour, frequency, associated sensations, anything else particular)

Taste preferences: salty, sour, sweet, bitter. Any other eating habits, particular cravings or aversions. Thirst, and how much you drink at a time and over 24 hours.

Details about the pregnancy and the birth: whether anything particular happened, the breastfeeding period, teething, the closing of the fontanelle, the age of the first unsupported steps, and the age of first words.