Paediatric Homeopathy Intake

supporting the lifeway of your little love

I'm so glad you're here seeking homeopathic support for your child. It was my own experience working with a homeopath to treat my first born that truly set me on this path, so trust me when I say that I know where you're at. Homeopathy is so gentle and effective for children and it can truly change the path of their life.

Please complete the intake form below. This is my departure point for understanding your child - their essence, and their struggles. During our initial consultation, we will discuss your child, their history, your family history and current dynamic more in depth so I can receive a full picture to help with prescribing the best remedies to support them.

Child Homeopathic intake Form

Please complete all the questions below. Allow yourself the space to consider your answer to each question, but definitely don't overthink things either. Provide as much or as little information & context for each question as you feel comfortable - there are no right or wrong answers. We will discuss everything during our initial consultation.

Your Name (first & last)

Your child's name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Child's Birthday

Year

Month

Day

Why are you seeking homeopathic support for your child? (Chief complaint)

What are the symptoms? Describe what you are able to observe. Detail is helpful!

When did this issue arise? What was happening in the child's life around that time? Do you have any idea what may have caused it?

Is there anything that aggravates or ameliorates the chief complaint? As in - have you noticed anything that seems to make it better or worse? Or more or less pronounced? (Think food, weather, temperature, light, movement, time of day, noise, etc.)

How is your child when they are at their best?

How is your child when they are at their worst?

How would you describe the emotional world of your child?

What (if anything) really bothers them or has a strong effect on them? How do they react?

How do they respond to consolation when they are upset? Do they want comforting? Does it help or do they push away?

What is their home life like? Can you briefly outline the overall family dynamic?

Have they experienced any major physical or emotional traumas or significant griefs?

Briefly share about your pregnancy with them and their birth.

How does the environment affect them? Think different kinds of weather, landscapes, storms, seasons. (If nothing stands out, leave blank)

What makes them feel scared or nervous or anxious? Do they have any specific fears?

Briefly share about their food & digestion. What do they like to eat? What food are they adverse to? How is their digestion? How are they when they are hungry and how are they after eating?

Briefly share about their liquid intake. What do they like to drink? Are they often thirsty or thirstless?

Briefly share about their sleep? Is there anything to note here? How are they when they wake in the morning?

How frequently do they get sick? What is the nature of their sickness? Do they recover robustly?

Briefly note any significant family health history that may be relevant. Parents, grandparents, and siblings general health.

Do they have any formal medical diagnoses? How are you treating any medical issues they are experiencing?

Current Medications and / or Supplements (if any)

Have they received their childhood vaccines? (You are not obligated to disclose this if you don't feel comfortable or it feels irrelevant). Have they had any notable vaccine reactions?

Do they generally run warm or cool - temperature wise?

Is there anything else you feel I should know about your child right now?

By checking this box and signing below, you agree that you have read, understood and agree to the terms outlined in the Student Case Study Consent Form. IT IS IMPORTANT THAT YOU TAKE THE TIME TO FULLY READ THROUGH THIS.

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held by her
herbs & homeopathy

supporting the lifeway of your little love

Child Homeopathic intake Form

BE HELD BY HER

HELP

NAVIGATE

CONTACT

beheldbyher@gmail.com
@held.by.her

supporting the lifeway of your little love

Child Homeopathic intake Form

BE HELD BY HER

HELP

NAVIGATE

CONTACT

beheldbyher@gmail.com @held.by.her

beheldbyher@gmail.com
@held.by.her