HealingHub - Child-Form

Kindly fill the form carefully, each question has a relevance!

Personal Information

Name :

Email:

mobile Number:

Age:

Basic complaints in details - since when, how did it start, what are the factors which increase or decrease the complaints?

Any other complaints? :

Any history of febrile convulsion, breath holding spasms ? :

Past history of illnesses(major illnesses,any surgeries, skin eruptions, nappy rash, worms, milk intorence, birth history, cry after birth ,mothers pregnancy history, also include mothers state of mind during pregnancy), milestones, vaccinations ? :

Any family history of illnesses ( parents, siblings, grand parents etc)? :

Medical History

How is his/her appetite ?:

What happens when he/She are hungry for long ? :

How is his/her thirst for water ? :

Similarly dislikes & any food which causes problems ?:

what are his likings in food , taste, any craving for abnormal things (pica) like chalk, mud, pencils etc?:

Any thumb sucking, nail biting, grinding teeth ,drooling of saliva or any such habits? :

Bowels / Stools -- Do you have any tendency for constipations or loose motions, are they fine ? :

Is his/her urination fine ? :

Sweat / Perpiration Do they sweat when they exert ot otherwise, area where they sweat, do they sweat on his/his palms & soles? :

Does it smell bad ? :

yes

Does the sweat leave stains on the clothes ? :

How is his/her sleep? Position of sleeping?Any Dreams? :

Thermally - How does his/her body react to heat or cold, can he/she tolerate heat more or cold more ?:

(FOR MOTHER) kindly describe your physical and mental health during pregnancy. Any specific cravings in food/dreams/any trauma etc in pregnancy? :

Mind -- Most important-- Please answer freely, frankly & Completely , please do not hold anything back be-open & forthright. Take help to answer if you find difficulty in answering a question or let me know if you do not understand the question.

How is his/her nature at home with family, in school, outside, with strangers etc? :

Let me know about your family structure-- Who all are there & How is his/her relation to each? :

Is he/she active, lazy or Hyperactive ? :

How is he/she emotionally? :

Is he anxious, fearful (example darkness , Alone, High places, Rides, Water, Animal, Strangers etc, ), stage fright ?, anxiety before exams-any symptoms ? :

Any anger bouts, effect of anger on him, response to being corrected or shouted at violent in any way? :

Any physical or mental hurt /trauma incurred, any separation history? :

What are the games he loves to play? :

How is he at keeping his things? :

Is he/she friendly or reserved? Do they mingle with other kids or relatives? :

How is his Scholastic /academic performance, extracurricular activities? :

What are the Future career aspiration/ambitions? :

Child Case

Kindly fill the form carefully, each question has a relevance!

Personal Information

Medical History