YES(Y) Indicates the child gets the problem regularly; NO(N) Indicates the child never had the problem; PAST(P) indicates the child had the problem in the past, but not recently. Please circle the correct one for your child.












































































































Does your child experience any of the following night time behaviors?






















































Please describe a typical day’s diet for your child

























GENERAL










SKIN































HEAD













EYES

























EARS






















NOSE



















MOUTH/THROAT



























NECK







RESPIRATORY






















CARDIOVASCULAR







BLOOD/LYMPH















URINARY
















CARDIOVASCULAR






























MUSCULOSKELETAL






















NEUROLOGICAL













MENTAL/EMOTIONAL




























Please answer the questions as carefully, thoughfully, and accurately as possible. Many of the questions may not seem directly related to your child’s problem or main complaint, however, each one may healp determine which homeopathic remedy is best suited for them. The information provided is not used in a judgemental way. It is purely to help the practitioner select the most appropriate remedy for your child. THe more specific, characteristic and/or unusual are some of the most important. Being as honest & accurate as possible is extremely important. 1means the least, 5 means the most.

Which weather conditions is your child most troubled by?

































Is your child generally sensitive to and/or troubled by:

























Answer as honestly as you can about your child’s personality traits.


















































































How often does your child have the following behaviors?
1=never, 5=a lot








































How often does your child make mistakes with the following?













Is your child forgetful of any of the following?



















How sensitive is your child to any of the following?




























How afraid is your child of the following?
1= not at all, 5= very afraid







































































YES(Y) Indicates the child gets the problem regularly; NO(N) Indicates the child never had the problem; PAST(P) indicates the child had the problem in the past, but not recently. Please circle the correct one for your child.

Does your child experience any of the following night time behaviors?

Please describe a typical day's diet for your child

GENERAL

SKIN

HEAD

EYES

EARS

NOSE

MOUTH/THROAT

NECK

RESPIRATORY

CARDIOVASCULAR

BLOOD/LYMPH

URINARY

CARDIOVASCULAR

MUSCULOSKELETAL

NEUROLOGICAL

MENTAL/EMOTIONAL

Please answer the questions as carefully, thoughfully, and accurately as possible. Many of the questions may not seem directly related to your child's problem or main complaint, however, each one may healp determine which homeopathic remedy is best suited for them. The information provided is not used in a judgemental way. It is purely to help the practitioner select the most appropriate remedy for your child. THe more specific, characteristic and/or unusual are some of the most important. Being as honest & accurate as possible is extremely important. 1means the least, 5 means the most.

Which weather conditions is your child most troubled by?

Is your child generally sensitive to and/or troubled by:

Answer as honestly as you can about your child's personality traits.

How often does your child have the following behaviors?
1=never, 5=a lot

How often does your child make mistakes with the following?

Is your child forgetful of any of the following?

How sensitive is your child to any of the following?

How afraid is your child of the following?
1= not at all, 5= very afraid