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:

Your Signature

* PLEASE NOTE :

The information provided on this site is for information and educational purposes only.  Information contained should not be taken as individual medical advice, nor is it intended as a substitute for consulting your doctor and/or healthcare practitioner.  All material presented on the blog ,newsletter or within its communications has been sourced from multiple authors and does not necessarily constitute the opinion of  InterConnective Health.It is provided for general information and educational purposes only.  Serious injury or illness should not be treated without expert advice, nor should the information we provide be seen as a replacement for a consultation with a trusted healthcare provider and General Practitioner. It is your responsibility to seek medical help and diagnosis when appropriate. All remedy related information is drawn from homeopathic pharmacopoeias and materia medicas referenced worldwide.

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