Questionnaire for Children
This form should be filled out by the mother, if possible, or parent or legal guardian

Child's Name DOB Age Weight at Birth Height/Length (if known)

Parents Day Phone  

Address Eve Phone Email

Address Parent's Marital Status Please Select... Married Single Significant Other Divorced Widowed Other

Step Parent's

What is the child's chief complaint?(CC)	When did the problem begin? What do you think caused it?
What aggravates the CC, (types of food, weather, noise, light anything you can think of)?	Try to specify what time of day or night is it worse?
What symptoms can you identify that accompany the CC?	What was your predominant emotional state while pregnant with this child?
During the pregnancy, did you suffer any particular shocks, or losses?	Did you take any drugs ?
How did your food cravings and aversions change during pregnancy?	Were there any complications at birth?
How many rounds of antibiotics has the child had, and for what?	Any Skin conditions treated with cortisone ?
At what age did the child reach these stages: Weaning Closing of fontanels First milk teeth Talking Toilet training First permanent teeth Crawling Walking	How did the child react to these situations?  Please try to think of mental and emotional reactions as well as any physical symptoms that may have developed. Vaccinations Birth of younger sibling Starting daycare regularly First day at school Spending the night with a friend  Traveling with the family Going away to camp etc. without the family
Did the child suffer from a childhood disease with very severe symptoms? (Measles, Chickenpox, German Measles, Croup, Mumps, etc.)?	When ill or upset, does the child tend to cling to you or want to be left alone?
What is the child's behavior in playing with other children? Does it make a difference if the other kids are older or younger?	What feedback do you get from your child's teachers about behavior in class?
What pets do you have, and what is your child's attitude towards them?  What types of food does your child crave? Please be as specific as possible and list as many as you can. What types of food does she/he refuse to eat? What types of food does your child react badly to, whether physically (bloating, diarrhea, etc) or  behaviorally, and what are the reactions?	Any fears that are unusual for a child your child's age? (of the dark, lightning, thunder, being alone) Are there nightmares? Yes No
Is the child chilly? Yes No Is there excessive perspiration on the head and/or feet?	Is the child very affectionate when not sick? Yes No Is the child unusually sympathetic (showing concern for the suffering of other children, animals, etc.)??
Does the child like music? What kind? Dancing? Do symptoms (like restlessness) improve with music?	Is the child obstinate? How is this expressed?
Is the child fastidious?	Is the child sensitive to criticism and reprimand?
Can you think of any unusual or distinctive things about your child's behavior, fears, fantasies, desires, attachments, preferences in clothing, etc.?	Give a timeline for the child with all possible traumas, diseases, important events, deaths in the family. Describe the reaction of your child towards these events.
Family History:	Submit form to Family Homeopathic Care Associates