Sophie Knock, Natural Health Practitioner

A natural path to body harmony and well-being.

Tel: 01458 830293
Mob: 07826 191769
sophie@holistichomeopath.co.uk

Children's Homeopathy Questionnaire

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Sophie Knock - Holistic Homeopath

69a Roman Way, Glastonbury, Somerset, BA6 8AD
Email: sophie@holistichomeopath.com
Phone: 01458 830293 or 07826191769

Please fill in this form with as much detail as possible. All information is private and confidential.

 

Name of Parent
Address inc Post Code
Telephone (Work)
+44
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    Telephone (Home)
    +44
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      Mobile
      +44
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        Email *
        Do you give permission for me to contact your GP to discuss your child’s health and medical history where absolutely necessary?
        Yes
        No
        Name of Child *
        Date of Birth of Child
        Describe briefly your main reason(s) for consulting a homoeopath for your child
        List any medication the child is currently taking (including orthodox pills, vitamins and food supplements). Please state for how long and for what reason the child is taking them
        Give details of anything that you are allergic to: foods, drugs, animals, pollen etc
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        Family Health History

        Family Health History Please indicate whether any of the child’s parents, grandparents or siblings have suffered or died from any serious medical condition or illness (include cancer, TB, allergies, heart, thyroid, mental problems, diabetes, alcoholism, drug abuse, early death, venereal disease etc)

        Personal Health History

        Please fill in this section giving as much information as possible including dates.  Remember to mention your approximate age at the time of any health problems.

        How was the pregnancy and birth, any complications or emotional issues around that time? Was Breastfeeding OK?
        Infectious Childhood Diseases: (measles, mumps, chicken pox, whooping cough, glandular fever etc. - age and state if mild or severe)
        Any adverse reactions to immunisations/vaccinations?
        Injuries and accidents
        Operations and surgical procedures
        Skin: Warts, verrucae, herpes (cold sores), abscesses, boils, moles, eczema, impetigo etc.
        Weather and reaction to the environment (what weather suits the child best? Does he/she feel the cold / heat / wind / draughts / damp / humidity? Do they prefer warm rooms or fresh air? Etc)
        Appetite & thirst: (what foods/drinks/flavours/condiments etc. does your child crave or have a strong dislike of? does any food or drink cause an adverse reaction? how thirsty are they?)
        Blood Group
        Fears or phobias: (For example - heights, closed spaces, dark, germs, ghosts, animals, insects, snakes, spiders, storms, examinations, disease, poverty, failure etc.)
        Dreams: (Any dreams that stay in their memory. Any recurring dreams. Please try to recall at least one dream that the child has told you about).
        Nature or character; how would you or others describe the child
        When they are angry what does the child do, describe it from beginning to end
        Favourite toy and why?
        Favourite book, film, story etc and why?
        How do they react around other children, adults, strangers?
        How do they react around other children, adults, strangers?
        Any other health problems including life traumas, griefs, shocks etc.?
        What upsets the child the most?
        What is the worst thing that has ever happened to the child and how did he/she react?
        What makes them the happiest?
        Any thing else you would like to share before the consultation?
        Accept Terms *

        I have read and agree to the Privacy Policy

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