PEDIATRIC HOMEOPATHIC INTAKE FORM

Please take the time to be as thorough as possible in filling out this form. It will help us determine the correct constitutional homeopathic remedy for your child. Not all questions will apply to every child. Only answer those that pertain to your child.

In your opinion, what are your child’s most important health concerns?

Food:

Thirst:

Is your child thirsty?

Clothing:

Are they intolerant to tight fitting clothing, specifically around the neck?

Sleep:

Does your child wake up refreshed and rested?

General Information:

Check how each of the following influences your child’s well-being or problem they may be struggling with...

Cold:
Damp:
Sun:
Open Air:
Heat:
Storms:
Wind:
Stuffy Air:
Change of Weather:
Ocean / Seashore:
Physical Exertion:
Bath:
Moonlight:
Mountains:
Upon Rising:
Warm Application:

SYMPTOMS:

Please mark, (1) = Mild, (2) = Moderate, (3) = Severe

Next to the following symptoms which apply to your child now or in the past.

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Anger:

Do they experience uncontrollable rage?
Do they have difficulty expressing anger?

Sadness:

Does your cry easily and/or often?

Grief:

Fears:

Child's Description:

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