Homeopathy Specialty By Deven Negi
Homeopathic Case Taking For CHILD
IDENTIFICATION
Name of child:
Name Parent(s):
Status:
occupation:
Home Address:
City:
Prov:
Postal code:
Contact Numbers:
Email:
Child’s Date of Birth:
Age:
Sex:
phone:
Weight:
Cell:
Hreight:
H/o Previous consultation of Homeopath or any doctor–
H/o previous medication of child –
Chief complaints With L/M/S/Concomittants / time
1.
2.
3.
4.
5
MOTHER’S PREGNANCY HISTORY
History of abortions –
History of pregnanciesPregnancy by –
Treatment during pregnancyComplications of pregnancy –
Types of laborComplications of labor-
2100 Ellesmere Rd Unit 211- E Toronto Scarborough ON M1H 3B7, Canada, Contact : (647) 216 1531
Homeopathy Specialty By Deven Negi
Child weight at birthChild health condition at birthTypes of delivery of child –
Mention the medications or habbits during and after pregnancy.
Childhood Past History of
Please check √ if ever had any of these conditions:
Hyper-hypo activity :
Milk intolerance
Sleeping problems :
Bedwetting
Learning problems
Growth problems
Crawling/Standing/Walking Difficulties
Allergies
Speech / Language Difficulties
Eczema
Behaviour problems
skin rashes
Anxiety depression/sadness
psoriasis
Convulsions
Milk intolerance
Milk intolerance
Bedwetting
Hyper-hypo activity :
Milk intolerance
Sleeping problems :
Bedwetting
Learning problems
Growth problems
Crawling/Standing/Walking Difficulties
Allergies
Speech / Language Difficulties
Eye infections
Behaviour problems
Ear infections
Anxiety depression/sadness
nosebleeds bleeding
Convulsions
gums & tooth diseases foul odours
Hyper-hypo activity :
(stool/breath/sweat/urine)
Hyper-hypo activity :
Eye infections
Ear infections
loss of appetite
nosebleeds bleeding
excessive appetite
Constipation
eating disorder of indigestible things
diarrhea
loss of appetite
Vomiting
excessive appetite
Worms
eating disorder of indigestible things
Jaundice
Tuberculosis
Colic
Recurrent cough
Tuberculosis
Asthma
H/o Heart disease, CNS , DM, HT, Thyroid , Cholesterol, Addictions, Family history of
CA, Tuberculosis, Skin diseases
OperationsInjuries -
2100 Ellesmere Rd Unit 211- E Toronto Scarborough ON M1H 3B7, Canada, Contact : (647) 216 1531
Homeopathy Specialty By Deven Negi
Vaccination complications
Child behavior information
Fears/phobias (specify):
Lack of confidence:
Excess timidity/shyness:
Makes friends easily:
Likes to be with friends:
Prefers to be alone:
Prefers one parent:
Aversion to being carried/ rocked:
Better when rocked or carried:
Rejects attention when sick:
Startles when being put down or going down stairs:
Hard to please:
Gets angry easily:
Noise sensitive:
Biting / kicking /head-banging etc:
Aggression:
Violence/cruelty:
Passivity:
Affectionate:
Averse to being held:
Laziness:
Resistance to change…..
Motion sickness…….
Seems to learn slowly...........
Easily distracted………
Difficult concentration……..
Sleeps long hours,
Hard to wake in the morning..............
Needs little sleep………….
Kicks off covers…..
Prefers cold room…..
Prefers hot room
Excessive crying
.Easily weepy....
.Aversion to bathing…..
Prefers fresh air…….
Prefers to be wrapped/covered…….
Nightmares(specify)....................................
2100 Ellesmere Rd Unit 211- E Toronto Scarborough ON M1H 3B7, Canada, Contact : (647) 216 1531
Homeopathy Specialty By Deven Negi
Wakes with a start.......
Eyes sensitive to light................
Dyslexia………
Oppositional behavior…….
Obstinacy……..
Disobedience………
Lying…...
Compulsiveness…….
Grinds teeth.
Nail-biting.......
Excess scratching and picking of skin, ears, nose and/or anus.............
Inclination to masturbath
Food cravings, intolerances, allergies or
aversions(specify)……………………………………….
Favourite toys, games, hobbies, activities, sports
Academic history & aptitudes
Family History of disease
Father
Paternal Grandfather
Paternal Grandmother
Mother
Maternal Grandfather
Maternal Grandmother
Sister (s)
Brothers (s)
Aunts (s)
Uncles (s)
The information contained herein is strictly confidential. Please fill out this questionnaire
completely and to the best of your knowledge. Even the smallest details are important.
2100 Ellesmere Rd Unit 211- E Toronto Scarborough ON M1H 3B7, Canada, Contact : (647) 216 1531