QUESTIONNAIRE FOR CHILDREN

Child's First Name:
Age:
Height:
Weight:
Birth weight:
Hair color:
Race/nationality:

1. What is the chief complaint? Include information about the side of the body that's affected; the color, odor and consistency of any discharges that may be present; whether the complaint came on gradually or suddenly; and all changes from the normal state, including mental/emotional changes, body temperature changes (colder or hotter than usual), appetite and food and drink desires that may have changed; and try to be specific in describing the sensations involved in the complaint, for instance, "pain as if a splinter in the throat", etc.

2. When did this problem start? What happened in the child's life around that time? What do you think caused it?

3. What aggravates the chief complaint (certain foods, weather, movement, light, noise, touch, pressure, music, heat, cold, open windows, closed windows, being at the sea shore, sympathy or anything else you can think of)?

4. What makes the chief complaint better? (See examples above.)

5. What time of day is the worst for your child (try to specify a time)?

6. What symptoms accompany the chief complaint? Examples might be headache with runny nose or runny eyes, stomach pains with irritability, and so on.

7. What was the mother's and father's state of health at time of conception? How did the mother feel during pregnancy physically and mentally? Did she suffer any shocks or traumas while pregnant?

8. Did the mother have any unusual or memorable dreams while pregnant?

9. Did the mother take any drugs while pregnant?

10. Were there any complications at birth?

11. At what age did the child: crawl, walk, talk, teethe, toilet train, wean?

12. How did the child react to the following situations: vaccinations, birth of younger sibling, starting day care, starting school, spending night with a friend, going away to camp, traveling with the family?

13. How many rounds of antibiotics has the child had and for what conditions?

14. Any skin conditions treated with cortisone-type cream?

15. Did the child have an especially severe childhood illness--measles, mumps, croup, etc.?

16. When ill or upset does the child want to cling or be left alone, or something else altogether?

17. How would you describe the child's behavior when playing with other children?

18. What feedback do you get from the child's teachers?

19. How does your child treat animals?

20. What foods and drinks does your child crave? What foods is he or she averse to? Are there any foods he or she reacts badly to and in what way? Do the drinks have to be cold (or with ice) or can they be any temperature?

21. What fears does your child have?

22. Is the child chilly or warm? Is there excessive perspiration anywhere?

23. How affectionate is the child when not sick?

24. How sympathetic is the child (concerned with the suffering of others)?

25. How is the child affected by music and dancing?

26. What emotion tends to predominate with the child?

27. Is the child fastidious? Please explain.

28. Is the child sensitive to criticism and reprimand? Give examples.

29. Describe the child's eating habits, for example: picks at his food, or eats voraciously, or is full after 2 bites, or can't sit still to eat, or must be fed or he won't calm down, and so on.

30. Are there any digestive complaints--waking with stomach pains, or a lot of gas and bloating or burping, or constipation, etc.?

31. Are there any problems associated with sleep? What position does he sleep in? Does he throw the covers off? Does he sweat during sleep? On which part of the body? Trouble falling asleep? Nightmares, etc.?

32. Any skin symptoms or anything note-worthy about the skin, the complexion, etc.?

33. Is there anything striking, or characterizing about your child, for example: attatchments, unusual desires and abilities, preferences in clothing, etc.?

34. How cooperative is the child?

35. What's standing in his way of getting what he wants or needs?

36. How often does the child get sick? Does he tend toward certain illnesses?

37. What illnesses run in the family, including the grandparents?

38. What does the child really love to do?

39. It's important for us to know what may have been the cause for the complaints you have mentioned. To this end, please make a list, in order of occurence, of the major events in the child's life, including such things as physical and emotional traumas, major illnesses, losses, deaths in the family, surgeries, etc. and the child's age at the time. If he or she had a notable reaction to these events, please describe.

THANK YOU!!!!!

[ 18. May 2003, 00:34: Message edited by: Snoopy ]

During a lecture at college we were told to ask about dreams Mum had during pregnancy and also about the circumstances going on around conception in case of any trauma then with Mum or Dad.

__________________
RSHom - Registered Homeopath

Does anyone think this questionnaire is missing
one or more significant questions?

Snoopy

if i may i have few more thing that can be asked:
1.for whom the child look like-appearance or behavior [its good thing to ask because u can learn more ]
2.if the child speak u can ask what punsihment u hate the most [u can know from it if he like to be outdoor or like to be with people or just watch movie]
3.what kind of t.v progrems do u lie [war,funny,etc]
4.tell me about your brothers and what u hate about them or like [ u can see jealousy,etc]
5.which proffesion do u like in school and why

i have few more so if u want i will send
all the best