Homeopathy Questionnaire for Children

Children’s Homeopathy Questionnaire

• Download the Microsoft Word document of the Children’s Homeopathy Questionaire

Homeopathy Questionnaire for Children

What is your child’s name?

What is your child’s date of birth?

What is your mailing address?

What are your phone numbers?

What is your Skype address?

Please answer as many of the following questions as you can in preparation for your initial consultation.  If you find this difficult to do, don’t worry about it, we will explore further during your child’s session, and I will help you tell me the story of your child’s illness.  If there is anything you feel uncomfortable discussing in front of your child, you may  write it here or e-mail it to me.

Please tell me about the genetic background of the family:  diseases of parents, grandparents and siblings.

Physical Sphere

1)     What are your child’s physical health complaints?  When did they begin?  What makes them better or worse?

2)     Please tell me about the illnesses your child has had?  How often does the child get sick?  How does she or he behave during an illness?  How does she  appear (pale, flushed, etc.)  What medication or treatments have you used for your child during illnesses?  Are your child’s  illnesses accompanied by fevers?  If so, how high do they go?

3)     Does the child have any problems with digestion or elimination?

4)     Does the child have any skin problems?

5)     Has your child been vaccinated?  Did he or she have any reactions to the vaccines?

6)     Please tell me about your child’s eating habits?  What are his or her food cravings, sensitivities, or aversions? Does the child like eggs?

7)     What does the child eat on an average day for breakfast, lunch, dinner and  snacks?

8 )     How thirsty is the child?  What beverages does the child drink and how often?

9)     Does the child run on the warm or cold side?  Are any body parts colder or hotter than others?  Does the child keep covered during sleep?

10)    Does the child have a tendency to perspire during the day or night?  Where?

11)    What are the child’s physical and emotional responses to the different weather conditions  (sunny weather, thunder and lightning storms)?

12)    Does the child have any sleep problems?  Is there a sleep position that the child favors?  What time does the child go to sleep at night and wake up in the morning?

13)    At what time of the day is the child’s energy level at its highest?  When is it at its lowest?  Is the child hyperactive at any time of the day?

14)    For girls who have started menstruating:  are there any problems with cramps?   Does she have any PMS symptoms?

15)    What are the medications that the child is currently taking?

16)       Has your child had homeopathic treatment in the past? Please let me know the remedies he or she has taken, the potencies, the dates you took them and about their response to the different remedies. Also, please me know about other treatments your child has had for their health conditions.

Personal History

1)     Please tell me the child’s personal history, starting with the mother’s pregnancy.

2)     Describe the first years, whether the child was colicky; how was her sleep, developmental milestones; when the child walked and talked.

3)     Family situation, relationship to parents and siblings.

4)     School – any learning or behavioral problems

5)     Playing with friends; how the child interacts with her peers.

Emotional Sphere

1)     What are the activities the child enjoys doing?  Does she enjoy travel?

2)     How moody is the child?  Does he or she tend to get angry or sad?  How does the child express these emotions?  Does the child have a tendency to cry?

3)     What are the child’s fears and anxieties?  Does she tend to worry?

4)     Is the child sympathetic?

5)      Is the child perfectionistic?  Is she neat or messy?  Does she like to be on time?

6)     Does the child throw tantrums?

7)     Is the child shy?

8 ) Does the child have any nervous habits?

9)     Does the child tend to have nightmares or recurrent dreams?

10)    How does the child respond to reprimands?

11)    Does the child tend to get envious or jealous?

12)    Is the child defiant, disobedient or stubborn?

13)    How is your child’s  self -confidence?

14)    What are the traits your child shares in common with his/her mother?  What are the traits your child shares in common with his/her father?

Mental Sphere

1)    Does the child have any problems with memory?

2)     How is the child’s ability to concentrate?

3)     Is the child religious?

4)     I occasionally  mentor other homeopaths.  Would you be willing to have another homeopath or student homeopath sit in on the case taking process  with your child?

Thank you for completing this questionnaire.