AuerFamily Homeopathy, LLC
Child Intake Form
Name:____________________________________ Birthdate:_______________________
Home Address:_____________________________ Phone:_________________________
City, Zip:__________________________________ Sex: M F Weight___Height____
Mother’s/Caregiver's Name:_____________________Phone:_________________________
Address:___________________________________________________________________
Father’s/Caregiver's Name:______________________Phone:________________________
Address:___________________________________________________________________
Siblings (Include ages):_______________________________________________________
__________________________________________________________________________
Pediatrician (Include name and address):
__________________________________________________________________________
Referred by:________________________________________________________________
Current School (Include Grade):________________________________________________
Person to be contacted in case of emergency:_________________Phone:______________
Birth History (Include birth weight, problems during pregnancy or after birth):
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Give the following information for the last times your child has been hospitalized starting with
the most recent including type of illness, month and year hospitalized, name of hospital, city
and state.
#1:_______________________________________________________________________
#2:_______________________________________________________________________
#3:_______________________________________________________________________
Allergies: __________________________________________________________________
Medications(Type, Dosage, Frequency):__________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Medicinal Herbs, Vitamins, Teas: _______________________________________________
Does your child use: ˙Coffee: Amount_________ ˙Cigarettes: ___________
Alcohol: Amount_______ ˙Other drugs: Amount_____
YEAR Tests/Immunization
_____Smallpox _____Polio
______DPT
______Hepatitis
______TB test
_____Typhoid
_____Tetanus ______MMR ______Other
______X-rays/Other
MINOR INTAKE FORM Page 2
Check for yes if your child has been bothered recently by any of these problems.
Y
Y
Y
-- frequent or severe headaches
-- earaches
-- recurring indigestion
-- back pains
-- running ears
-- frequent belching
-- neck lumps or swelling
-- hearing difficulties
-- nausea
-- loss of balance
-- noises in ears
-- vomiting
-- dizzy spells
-- dental problems
-- pain in abdomen
-- blackouts or fainting
-- sore or bleeding gums
-- bloated abdomen
-- sore tongue
-- motion sickness
-- wear glasses
-- sore throat
-- blurry vision
-- difficulty swallowing
-- constipation
-- eyesight worsening
-- hoarse voice
-- loose bowels
-- see double
-- black stools
-- see halos or lights
-- wheezing or gasping
-- gray or whitish stools
-- eye pains or itching
-- cough up phlegm
-- blood with stools
-- watering eyes
-- cough up blood
-- pain in rectum
-- chest colds
-- itching in rectum
-- congested nose
-- rapid or skipped heart beats
-- running nose
-- chest pains
-- frequent urination
-- sneezing spells
-- shortness of breath
-- involuntary urination
-- head colds
-- burning on urination
-- nosebleeds
-- swollen feet or ankles
-- black or bloody urination
-- armpits or groin swelling
-- weak urine stream
-- difficulty sleeping
-- aching muscles or joints
-- difficulty starting urine
-- excessive sweating
-- swollen joints
-- constant urge to urinate
-- night sweats
-- back or shoulder pains
-- fever or chills
-- weakness in arms or legs
-- trembling
-- warmer/colder than others
-- painful feet
-- numbness
-- leg cramps
-- skin problems
-- loss or gain of weight
-- painful feet
-- scalp problems
-- loss of appetite
-- bruise easily
-- always hungry
-- fatigue or weariness
-- nervousness or anxiety
-- nervous with strangers
-- difficulty relaxing
-- worry a lot
-- nail biting
-- difficulty making decisions
-- lack of confidence
-- scary dreams or thoughts
-- shy or sensitive
-- dislike criticism
-- angered easily
-- annoyed by little things
-- family problems
-- problems at work
-- lack of concentration
-- loss of memory
-- hopeless outlook
-- feeling of desperation
-- lonely or depressed
-- frequent crying
-- considered suicide
MEN/BOYS ONLY
-- early or late puberty/developmt
– burning/discharge
-- swelling on/of testicles
-- painful testicles
WOMEN/GIRLS ONLY
-- early or late onset menses
-- irregular periods
-- missed periods
-- menstrual problems/PMS
-- bleeding between periods
-- heavy bleeding
-- bearing down feelings
-- vaginal discharge
-- genital irritation
-- swelling of breasts
____ # of pregnancies
____ # of births
____ # of miscarriages
____ # of premature births
____ # of caeserean sections
____ # of abortions
Comments or Special Problems: The main reason for today's appointment?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
MINOR INTAKE FORM Page 3
What are you most sensitive to (e.g. noise, odors, light, pain)?_________________________
__________________________________________________________________________
__________________________________________________________________________
Describe an ideal day in terms of weather and temperature: __________________________
__________________________________________________________________________
What are your fears?_________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Do you have any hobbies, what are they?_________________________________________
__________________________________________________________________________
__________________________________________________________________________
(Women/girls only) What symptoms do you experience premenstrually?
__________________________________________________________________________
__________________________________________________________________________
Describe any recurrent dreams, important dreams in your life or recurrent themes in
your dreams: _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
How is your energy? Is there any particular time of day when it is lower or
higher?____________________________________________________________________
__________________________________________________________________________
What environment do you feel most comfortable in? (e.g. desert, mountains,
ocean, city)_________________________________________________________________
__________________________________________________________________________
What is your favorite color?______________Least favorite color?______________________
What foods do you crave or most like to eat?_______________________________________
__________________________________________________________________________
__________________________________________________________________________
What foods do you most dislike?________________________________________________
__________________________________________________________________________
How is your thirst?___________________________________________________________
What temperature do you like drinks? ____________________________________________
Are there any foods that you are sensitive to or allergic
to?_____________________________________________________________________________
___________________________________________________________________________________
MINOR INTAKE FORM Page 4
Family History: Place an (X) in the appropriate columns for any illnesses that your child
or your relatives have had.
ILLNESS
Child
Father
Mother
Brothers
Sisters
Grandparents
ALLERGIES
ANEMIA
ARTHRITIS/GOUT
ASTHMA
ALCHOHOL/DRUGS
BLEEDING PROBLEMS
CANCER
EPILEPSY
DIABETES
ECZEMA
EMPHYSEMA
HEARTH TROUBLE
HEPATITIS
HIGH BLOOD PRESSURE
FREQUENT INFECTIONS
KIDNEY PROBLEMS
MENTAL ILLNESS
MIGRANES
ABNORMAL PERIODS
PSORIASIS
PNEUMONIA
POLIO
PROSTATE PROBLEMS
RHEUMATIC FEVER
STOMACH PROBLEMS
STROKE
THYROID PROBLEMS
TUBERCULOSIS
ULCERS
VENEREAL DISEASE
WEIGHT PROBLEMS
Comments, including known diseases your family is prone to:__________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________