New England Holistic Health Center
Wellness for the Mind and Body
155 Sycamore Street, Glastonbury, CT 06033 Tel: (860) 659-3553 Fax: (860) 659-0744
www.NewEnglandHolisticHealth.com
Pediatric Homeopathic Intake Form
Instructions for Homeopathic Intake form
Please answer the questions on the following pages as carefully, thoughtfully, and accurately as
possible. Many of the questions may not seem directly related to your child’s problem or main
complaint, however, each one may help determine which homeopathic remedy is best suited for
your child. The more specific, characteristic, and/or unusual are some of the most important.
Anything that doesn’t apply, write in N/A.
Name of Child: ______________________________________
Child’s Date of Birth: __________________________________
Name of parent/ guardian: _______________________________
Today’s Date:
__________________________
The following general symptoms pertain to your child as a whole person.
Pick the number closest to the weather that troubles your child the most.
Which weather conditions is your child most troubled by? Can circle more than one.
Cloudy Clear Wet Dry Damp cold Snow (dry cold)
1=least troubled; 10=Most troubled
Storms
1-10 ____ Wind
1-10 ____
Fog
1-10 ____ Hot Sun
1-10 ____
Which seasons cause the most trouble?
Winter
Spring
Summer
Fall
Which is worse being in the: Mountains or Sea shore
For the following, 1= not sensitive; 10= very sensitive
Rate sensitivity to and/ or troubled by:
Bright Light
1-10 ______
Darkness
1-10 ______
Open Air
1-10 ______
Stuffy rooms
1-10 ______
Tight Clothing
1-10 ______
Noise
1-10 ______
Odors
1-10 ______
Drafts
1-10 ______
Is your child generally chilly or warm or neither? __________________________
Which is your child generally most sensitive to, warm or cold?___________
What times of day is your child generally WORST (mood, energy, symptoms)?
Worst: ________AM
_________PM
What times is he/she BEST?
Best: ________AM
_________PM
Which symptoms does your child experience during sleep? Can pick more than one:
Teeth Grinding, restlessness, talking, perspiration, frequent urination, excess heat or cold,
laughing, snoring, nightmares, recurring dreams, sleepwalking.
When your child sleeps, what does he/ she prefer? Can pick more than one:
Without covers, partly covered, fully covered (not including head), fully covered (including head),
with arms or legs out of covers, without clothing, with a fan or air blowing on them, with window
open.
What position does he/ she sleep in most often?
Right side, left side, on back, on abdomen, knees pulled into chest.
How much does your child perspire? Never Sometimes All the time
If so, where do you notice your child sweating the most?
_______________________________________________
Does your child have difficulty waking?
Never
Sometimes
All the time
Does he/ she wake unrefreshed?
Never
Sometimes
All the time
Food Desires and Aversions:
In the following questions ask your child how much they desire or are averse to a particular food or
taste. Please answer from the point of view of their natural desires, not your knowledge of
nutrition. For example, they may never eat fatty meat because this is known to increase
cholesterol; however they do love the taste of fat. Answer the question that your child likes fat.
Strongly desire or crave a food or taste, mark 10.
Detest a food or taste, mark 1.
Tastes:
Foods:
Sweet:
1-10 _____
Refreshing:
1-10 _____
Sour:
1-10 _____
Apples:
1-10 _____
Salty:
1-10 _____
Bacon:
1-10 _____
Bitter:
1-10 _____
Bread:
1-10 _____
Spicy (hot) 1-10 _____
Bread w/ butter
1-10 _____
Smoked:
1-10 _____
Butter alone:
1-10 _____
Juicy:
1-10 _____
Cheese:
1-10 _____
Chocolate: 1-10 _____
Oranges:
1-10 _____
Pungent:
1-10 _____
Bland:
1-10 _____
Foods continued:
Pastries:
1-10
Fruit:
1-10
Ham:
1-10
Ice Cream: 1-10
Lemonade: 1-10
Milk:
1-10
Oysters:
1-10
Vegetables: 1-10
_____
_____
_____
_____
_____
_____
_____
_____
Eggs:
Fruit (sour):
Ice:
Indigestible things:
Meat:
Nut butters:
Pickles:
Vinegar:
1-10
1-10
1-10
1-10
1-10
1-10
1-10
1-10
_____
_____
_____
_____
_____
_____
_____
_____
Fish:
1-10 _____
Pork:
Fat (from meat) 1-10 ____
Grains: (pasta, bread, cereal, etc.) 1-10 _____
1-10 _____
Temperature of food: Which does your child prefer?
Warm food Cold food
Warm Drinks
Cold drinks
Does your child notice any specific tastes in their mouth (like metallic, bitter, foul, etc.)?
_______________________________________________________
How thirsty is your child generally?
Not at all
Sometimes
Very
Mental and Emotional State:
How much does your child worry about the following? Mark 10 for the most, 1 for the least.
Creative activities/ is very creative1-10 _____
Emotions/ Emotional
1-10 _____
Health, worries about health
1-10 _____
Morals/ past indiscretions
1-10 _____
Worries about Others (family & 1-10 _____
Close friends) well being
Religion
1-10 _____
Social life
1-10 _____
Social position
1-10 _____
The future
1-10 _____
School
1-10 _____
Irresolution (not being able to
1-10 _____
decide or stick to a decision)
Capriciousness (willfulness,
1-10 _____
changeable and erratic desires that are difficult to satisfy)
Selfishness
1-10 _____
Frightened easily
1-10 _____
Never afraid
1-10 _____
Answer as honestly as you can about their personality traits that you’ve noticed. Circle if
they are one or the other. If neither fits them, then don’t circle any of them.
Stingy
Overly generous
Thrifty
Extravagant
Hurried/ impatient
Slow
Messy
Fastidious
Calm
Restlessness
Indolence (lazy)
Always busy
Shyness/timid
Outgoing
Anger
Mildness
Lack of moral sense
Guilty
No religious feeling
Highly religious feeling
Obstinate (stubborn)
Yielding
Heedless/reckless
Cowardice
Social/antisocial. In regards to being with other people or in company?
Aversion (prefers to be alone)
Desire for (prefers to be around people)
Mark the expression that best describes your child’s feelings about the following issues if
applicable:
Significant past emotionally traumatic events:
Resolved, dwells on past, inconsolable, remorse, guilt.
Feeling towards the people your child is close to:
Loving, affectionate, indifferent, resentment, hatred.
Feeling toward disease/ condition:
Optimistic, doubtful of recovery, discouraged, fearful, despair of recovery.
Feeling toward life:
Love life, indifferent, bored, weary of life, loathing of life, desires death, suicidal thoughts, suicidal
disposition.
How much does your child have the following symptoms? 1=hardly ever; 10= always.
Irritability
1-10 _____
Jealously
1-10 _____
Moodiness
1-10 _____
Alternating moods 1-10 _____
Even moods
1-10 _____
Mark which best expresses your child’s general mood:
Morose, sad, apathy/indifferent, happy, excitement, exhilaration.
How does your child experience sympathy or consolation?
Likes sympathy
Dislikes sympathy
Better from sympathy
Worse from sympathy
How is your child in general around others?
Aversion to talking Talkative
Only talks when prompted
Not trusting
Trusting
Gullible
Suspicious
Doesn’t respond
How often and easily does your child weep?
Never
Sometimes
Often
How often does your child experience clairvoyance?
Never
Sometimes
Often
How is their level of self-confidence?
Lack of confidence
average
How impulsive is your child?
Never
sometimes
Pride/ Haughty
Often
How afraid is your child of the following? (1, never; 10, very afraid;)
Animals
1-10 _____
Being alone
1-10 _____
Death
1-10 _____
Relative’s death
1-10 _____
Impending disease 1-10 _____
Downward motion 1-10 _____
Evil
1-10 _____
Failure
1-10 _____
Falling
1-10 _____
Ghosts
1-10 _____
Heights
1-10 _____
Insanity
1-10 _____
Misfortune
1-10 _____
Of a crowd
1-10 _____
People
Snakes
Strangers
Darkness
Water
1-10
1-10
1-10
1-10
1-10
_____
_____
_____
_____
_____
Robbers/ intruders 1-10 _____
Spiders
1-10 _____
Wind
1-10 _____
Thunderstorms
1-10 _____
That something will happen 1-10 _____
Is your child forgetful of any of the following? (1 not at all, 10 a lot)
Dates
1-10 _____
Names
1-10 _____
Numbers
1-10 _____
Of words
1-10 _____
Of what someone else just said to you 1-10 _____
Of what you just said
1-10 _____
How often does your child make mistakes with the following?
Numbers
1-10 _____
Words (reading)
1-10 _____
Words (speaking) 1-10 _____
Words (writing)
1-10 _____
How sensitive is your child to any of the following?
Beauty
1-10 _____
Criticism
Cruel stories
1-10 _____
Frightening things
Being made fun of 1-10 _____
Music
Reprimand
1-10 _____
Rudeness
The suffering of others 1-10 _____
1-10
1-10
1-10
1-10
_____
_____
_____
_____
How does your child handle conflict usually?
Quarrelsome
Yielding
How is your child in regard to authority?
Bossy/ dictatorial Yielding/ fawning
How critical is your child of others?
Not at all
Sometimes
All the time
How often does your child reproach (find fault, scold, or blame) him/ herself?
Not at all
Sometimes
All the time
How honest is your child?
Always Lie
Somewhere in the middle
Always honest
How often does your child have the following behaviors? 1=never; 10= all the time
Abusive
1-10 _____
Biting
1-10 _____
Breaks things
1-10 _____
Contrary
1-10 _____
Cursing
1-10 _____
Disobedience
1-10 _____
Insolent
1-10 _____
Rage
1-10 _____
Rudeness
1-10 _____
Striking others
1-10 _____
Striking self
1-10 _____
Violence
1-10 _____