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Step 4. Patient's Questionnaire

Case History form for children below 12 years, for Developmental disorder and Autism cases.

1.   Personal History:

Patient Name :
Date of Birth :
Age :
Gender :
Birthplace :
Height :
Weight :
Parents Name :
Are Parents :
(Married / Single / Divorced / Living together)

2.   Chief Complain in detail :

Onset :
Duration since :
Diagnosis, if any made by physician :
What worsens / eases these symptoms ? :

3.   General information :

(a.)  Appetite:
Tendency to indulge in certain foods :
Any particular likes/dislikes for food? :
(b.)  Thirst:
Thirst:How much thirst do you have? :
Any particular time are you specially thirsty ? :
(c.)  Temperature:
More tolerant to :
Weather you are most comfortable in:
(d.)  Perspiration:
profuse/scanty? :
Do you perspire on the palms or soles? :
Is the sweat warm, cold, clammy, sticky, musty, greasy, stiffens the linen etc.? :
What is the smell like ? e.g. foul, pungent, sour, urinous:
(e.)  Urine:
Any problem about urine ? :
Any strong smell? Like what ? :
Do you have any trouble before, during and after passing urine ? :
(f.)  Sleep:
Quality of sleep :
Activity in sleep :
(g.) Dreams:
 
Dreams :

(h.) Teeth, Gums:

e.g. (carious teeth, bleeding gums. swollen gums.)
 
Teeth , Gums :
(i.)  LIPS
 
(Cracked, peeling of skin etc) :
(j.)THROAT
 
THROAT (including tonsils ) :
Any difficulty in swallowing? :

4.   Birth History :

1. Birth History : (Normal , C-Section . Forceps)
2. Was your baby born early ? :
How early ? :
Was your baby overdue? :
How late ? :
3. Birth Weight :
4. Complications after/during birth:
5. Did child cry immediately after birth ? If not then after how much time ? :
6.Problems during nursing child

5.   Past History :

Hospitalizations/ Surgeries/ Injuries / Any Medical History / Suffering from any disease ? :
Date Illness/ Injury/ Surgery duration of appearance/at age
Any illness/ Injury/ Surgery ? If yes at what age ? :
At present is on medication / any illness :
Milestone History :

Delayed or On time ?

Teething, any problem?

Sitting, Standing, Walking any difficulty?

Eating any indigestibles like chalk, lime, earth, slate-pencil etc.

Urine control / bed-wetting ?

Stool, toilet training any difficulty?

Any other problem about your growth & development?

Speaking – Words, sentence, stammering, speech difficulty?

Vaccination History :

Was there any reaction or particular trouble after any vaccination ? :
   Sensitivity :

Food disorder, Intolerance, Allergy.

Sun

Noise

Light

Tight clothing

Strong smell

 
Senses :
 

Eye- Eye contact, any movements

 
 

Ear- Hearing any problem

 
 

Nose- Motion of wings, picking nose, boring

 
 

Taste- Any marked craving or aversions

 
 

Touch- Any reaction or desire to touch.

 
 
PATIENT HISTORY :
Observation :

Physical Make-Up :

 

Height / Weight :

* Height: growth retarded / too tall / development arrested

* Delicate / dwarfed / obese

* Emaciation / thin/ sickly

 
 

Build :

* Lean / thin / emaciated…. obese, dull or active

* Emaciation / sunken / wrinkled / rounded face / deformed

 
 

Gait :

* Gesture makes strange attitude and position

* Reeling, staggering, tottering and wavering

* Stiffness, relaxation, flexed, crossing of Limbs
 
 

Face :

* Facial Features: shape of face – round, Chin tapering, strong
cheek bones.

* Facial Expression: anxious, childish, looks old, vacant, smiling Serious, frown, idiotic

* Discoloration on face

 
 

Hair :

* Thin / bald / thick / hard / brittle

* Thin / thick / curly / wavy

* Falling hair of – forehead / sides / vertex

* Grey becoming / in spots

* Loss of hair – beard / eyebrows / eyelashes

 
 
Mental Make-Up :
 

Expression General :

* Expressive : Vivaciousness, talkative, boasting, jovial, excitement

* Non-expressive: Introvert, haughty, egotism, sadness

 

 
 

Peculiar Gestures

* Peculiar gestures or behaviour, tics, odd blinking, grimacing, unnecessary smiling, giggling, serious, involuntary laughing, motion of head
* Any peculiar laugh pattern
* Weeping, screaming, noises making

 
 
Life situation:
Basic Nature :
 

Family nuclear or joint ?

 
 

Who takes care of child ? Are both parents working ?

 
 

How many siblings ? Relation with them ?

 
 

Any Particular Behaviour observed :

 
 

Incident from the child’s life when he/she very upset

 
 

Does he/she seem to get along well with others?

 
 

Reaction towards Strangers ?

 
 

Seems easy to handle ?

 
 

Have trouble changing activities?

 
 

Any Fears ? Experience nightmares?

 
 

Have sleep problems?

 
 

Have discipline problems?

 
 

Have bad temper?

 
 

Any time Startles in sleep?

 
 

Have temper tantrums?

 
 

Attend school? What grade?

 
 

Academic performance any problem?

 
 
If suffering from any Developmental Disorder
 

When parents realized about this Behaviour?

 
       
 

What peculiar Behavioral Symptoms was observed by parents?

 
       
 

Any improvement with age?

 
       
 

Child’s nature like father or mother?

 
 

Please tick mark once if the child or you as child had any of the following qualities : Tick mark twice if they are more intense :

 

Tick here

 

Tick here

Obstinacy

Unusual fears

Temper tantrums

Shyness

Disobedience

Unusual attachments (to whom)

Aggression

Habits like :- 

Hyperactivity

Biting nails

Destructiveness

Thumb-sucking

Courage

Picking and playing with anything ?

Possessiveness

Religious

Sibling jealousy

Dullness of memory

Any special skills

Slowness (in what)

Unusual desires(for what)

Laziness / Indolence

Telling Lies

Sensitive / Emotional

Mother’s history during Pregnancy :

Pregnancy History :

 

1. State of Mother during Pregnancy ?

 
   
 

2. Any major incident ? – About your birth :

 
       
 

3. Problems during Pregnancy

 
       
 

4. Substances used during Pregnancy :

 
 
Tobacco packs/day Alcohol : Drugs :
  5. Complications during delivery ?  
       
  6. Any Mental disturbance during pregnancy ?  

Please write in detail, if the mother suffered from any physical or emotional stress during pregnancy. Also describe the dreams the mother got during pregnancy.

Please describe any other aspects you feel are striking about the child.

 

This history record has been designed to facilitate our patients to assess their health issues in detail.

Once Homeopath Looks over this history record and reports she will be asking you specific questions pertaining to your symptoms to get a complete disease picture. Each symptom will be completed regarding its location, extension, sensation, modalities and concomitants during the virtual consultation process.

A complete case record thus created will be analyzed for a Homeopathic prescription. This is a confidential record and will be kept in the office. Information contained here will not be released to anyone without your authorization to do so.
 
     








Disclaimer: Online consultation gives you a chance to receive treatment that may not be possible to access in any other way. We do not guarantee you the results you may desire and will not be held responsible for the outcome of your treatment. Also, homeopathic remedies are non-toxic, safe and do not produce any side-effects. Any adverse health events that may occur must not be associated with your homeopathic treatment and we take no responsibility for these, if any.

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