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Intake form – Children

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This questionnaire is a confidential health assessment tool, which will assist in treating your child safely. This will also give me brief information about child health history before our online or in-person appointment. Please take the time to answer the questions as accurately as possible.

All fields with * are mandatory.

1. Personal information:

Child's name (*)

Parent/Guardian’s name (*)

Address (*)

Postal code (*)

Country (*)

Email (*)

Telephone (*)

Date of birth (*)

*Gender: (*)

Height (*)

Weight (*)

Family physician’s name and contact number

Please provide the name and contact information of an individual that we can contact in case of emergency. (name, relationship, contact number)

Has your child been treated with homeopathy before? if yes, please provide the name of the homeopath.

How did you hear about our homeopathic clinic? (internet, magazine/newspaper, referred by)

2. Current health concerns:

please give me a brief history about what brings you to homeopathy.
please list any health concern in order of importance to you.
Can you trace the origin of the present illness to any particular Circumstance such as accident, Illness, Incident? (E.g. Shock, Trauma, Worry, Errors In Diet, overexertion, exposure To Cold, Heat, Etc)

3. Medical history:

Please list any major surgeries that your child have had in the past.

Has your child had any injuries?

Has your child been vaccinated? Y ̈ N ̈ If yes, did you have any adverse reaction?

Has your child lost any weight recently? Y ̈ N ̈ If yes, How Much?

Date of last annual physical exam /blood test:

Does your child has any Internal Pins/Wires, Artificial Limbs, Special Equipment? Y ̈ N ̈ Please explain:

Any allergies/sensitivities (foods, drugs, pets, seasonal, etc.):

4. List of medication and supplements:

Please list any medication or supplements including homeopathic medicine or herbal medicines that you are already taking.

5.Child’s Birth History

Birth Weight

Rh Blood Problems?

Any complications during and/or after delivery?

Number of hours in labour

Was the delivery
At hospitalAt Home

Was the child breastfed? If NO, Type of formula used?

At what age was milk introduced?

At what age solid foods?

6. Mother’s Pregnancy History

Did you have any problems conceiving?

Did you have a stressful pregnancy?

Did you experience any of the following?

Did you use any of the following during pregnancy?
AlcoholAntibioticsIron supplementsRecreational drugsSleeping pillsother


Did you undergo

How much weight did you gain during pregnancy?

Did you have any food cravings or aversions during pregnancy? If yes, what were they?

During the pregnancy, did you suffer any shocks, traumas, or losses? If yes, explain

7. Child information:

Has your child experienced any Stress, Trauma, Loss or Life Changing Trauma in

Please check which of the following substances your child are currently using.
Alcohol how much?

Recreational drugs how much?

Sleeping pills how much?

Laxatives/Purgatives how much?

Pain killers how much?

Cigarettes how much?

Coffee or tea? How much?

Is your child is on any special diet? Y ̈ N ̈ Explain:

8. Sleep:

How many hours of sleep does your child get each night?

Does your child wake in the night for any particular reason?
At any particular time? How long does it take to fall back asleep?

Does your child wake feeling Rested? Y N

General energy level out of 10 (1=lowest, 10=highest)

9. Family History:

Please check any of the following ailments which may be present in your family history:

Please check ailments which may be present in your child’s family history:




Maternal grandmother

Material grand father

Paternal grand mother

paternal grand father

Is there anything else that you feel that hasn’t been addressed on this form?

Thank you for completing the questionnaire.