MEDICAL HISTORY FOR HOMEOPATHIC TREATMENT OF CHILD.

CHIEF COMPLAINT - (required)
Aggravated
Ameliorated:
Accompanying complaints
PRELIMINARY INFORMATION
Please supply following information about you as standard routine
Name of child -
Date of Birth -
Age -
Sex - Male Female
Vegetarian - Non-vegetarian - Eggs -
Habits: (Tick the correct options) Tea Coffee Milk Chocolate Others Specify
Family History - (Mention all relatives with whom you interact)
Hereditary/Genetic disease
Mention reason of Death of any members if not alive
POSTPARTUM HISTORY
Normal Forcep C - Section
GROWTH AND DEVELOPMENT HISTORY
Any health problems soon after birth
Any noticeable pregnancy health issues
Emotional issues with mother during pregnancy
Mention reason of Death of any members if not alive
Breast feeding difficulties if any
IMMUNIZATION HISTORY
PAST MEDICAL/SURGICAL HISTORY
Dietary/Food -
Desire and aversions if any
GENERAL ENVIRONMENT Hot Water Cold Water Situational
Sleep and dreams
Habits
Daily activities
Perspiration
Thirst
Stomach infections – (Tick the correct option) Nausea Vomiting Gas Pain Normal NA
Emotional nature
INTELLECTUAL ATTAINMENT
School performance
Extracurricular activities
Hobbies
Enclosures
1. Medical report and diagnosis of your physician.
2. Copies of reports of investigations done.
3. X-ray reports, Electrocardiograms, EEG, etc

Dr. Kalpana Kotecha | E: kalpanakotecha@gmail.com | T: +91 9323616462 | Skype id:kalpana.kotecha