Pediatric Homeopathic Intake Form | InterConnective Health

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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.

Child's Name

DOB

DATE

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

Which of the above problems are of most immediate concern to you?

How did these conditions develop? Are there traumatic events that can be identified as causing or clearly aggravating these problems?

Food:

List any food that your child craves or requests regularly, include any temperature or special preparation requests that accompany these cravings. (i.e. wants bread with crust removed or toast slightly burnt, also include spices and condiments, etc.)

How does the child respond to these foods?

List foods your child dislikes or is adverse to:

Thirst:

Is your child thirsty?

Yes

Amount of liquid in ounces ingested daily

Clothing:

Does your child have any clothing preferences?

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

Yes

Sleep:

Is there trouble falling asleep?

Waking in the middle of the night?

Is it easy to wake your child?

Does your child wake up refreshed and rested?

Yes

Are there any recurring dreams or nightmares?

What position does the child sleep in?

Is there a position the child cannot sleep in?

What does the child do with their covers at night? Do they wrap up tight? Do they throw them off? Do there feet stick out?

General Information:

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

Please list any of your observations:

What time of the day is your child's highest mood?

What time of the day is your child's lowest mood?

SYMPTOMS:

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

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

Prefer To Be With Company (Current)

Prefer To Be With Company (Past)

Prefer To Be Alone (Current)

Prefer To Be Alone (Past)

Afraid When Left Alone (Current)

Afraid When Left Alone (Past)

Would Rather Be Left Alone When Not Feeling Well (Current)

Would Rather Be Left Alone When Not Feeling Well (Past)

Forgetful (Current)

Forgetful (Past)

Mental Confusion (Current)

Mental Confusion (Past)

Decreased Concentration, Comprehension (Current)

Decreased Concentration, Comprehension (Past)

Makes Many Mistakes (Current)

Makes Many Mistakes (Past)

Critical of Self (Current)

Critical of Self (Past)

Critical of Others (Current)

Critical of Others (Past)

Lack Self Confidence (Current)

Lack Self Confidence (Past)

Suspicious/ Jealous (Current)

Suspicious/ Jealous (Past)

Sensitive To Noise (Current)

Sensitive To Noise (Past)

Organized, Neat and Clean (Current)

Organized, Neat and Clean (Past)

Affectionate (Current)

Affectionate (Past)

Assertive, Powerful (Current)

Assertive, Powerful (Past)

Confident, Secure (Current)

Confident, Secure (Past)

Intimate With Others (Current)

Intimate With Others (Past)

Easily Bullied (Current)

Easily Bullied (Past)

Shy With Others (Current)

Shy With Others (Past)

Lies (Current)

Lies (Past)

Does Things Without Conscience (Current)

Does Things Without Conscience (Past)

Anxiety (Current)

Anxiety (Past)

Restlessness (Current)

Restlessness (Past)

Excessive Worry (Current)

Excessive Worry (Past)

Depression (Current)

Depression (Past)

Despair/ Disconnect (Current)

Despair/ Disconnect (Past)

Loneliness (Current)

Loneliness (Past)

Mood Swings (Current)

Mood Swings (Past)

Argumentative (Current)

Argumentative (Past)

Defiant (Current)

Defiant (Past)

Have Any Fears (Current)

Have Any Fears (Past)

Please describe fears, if any:

Anger:

Do they get angry often?

Do they experience uncontrollable rage?

Yes

Do they have difficulty expressing anger?

Yes

How do they express anger?

Sadness:

What makes your child sad?

What do they do when they are sad?

Does your cry easily and/or often?

Yes

Does being consoled help?

Grief:

List major experiences of grief/loss in your child's life:

Fears:

What fears does your child have?

Are any of your child's fears unmanageable?

Other:

Are there any known episodes of physical, emotional, sexual abuse in your child's history?

Who are the most important people in your child's life?

How does your child relate to most people in your child's life?

What do you feel is your child's major mental and/or emotional limitations?

What does your child read for enjoyment?

Child's Description:

In 1-2 paragraphs, write a short description of your child currently. Include strengths, weaknesses, and major personality characteristics.

Your Signature

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