Child Intake Form for Homeopathy


Natural Treasure Holistic medicine
Mohamed El Siddig , NSHS, DMHS ( HD)
Homeopathic Doctor & Healer
Hypnopath/ Psychopath
Hamilton ,ON
Barton East
2892441179

Homeopathic consultation is facilitated when there is a complete picture of the individual’s mental, emotional and physical states of health.  This includes symptoms that affect both physical sensations (what does it feel like), and function (how it impacts you) and what ameliorates or aggravates each symptom.

Your Name (required)

Address (required)

Home Phone (required)

Work Phone

Cell Phone

E-Mail

Birthdate of Child (required)

Birthdate location (required)

Medications currently taking (required)

Vitamins or nutritional supplements currently taking (required)

Allergies to medications (required)

Allergies to foods (required)

Allergies to milk or dairy (required)

Did you have the normal or no childhood diseases? (required)

Standard vaccinations?

Question for Parents

Pregnancy

What was your (or birth mom’s) predominant emotional state when pregnant with this child?

During the pregnancy, did you suffer any particular shocks or traumas or losses?

Did you take any drugs during your pregnancy?

How did your food cravings and aversions change during pregnancy?

Were there any complications at birth?

Child Development - (Answer those that apply)

At what age did your child reach these stages? (months)

Weaning?

Talking?

Crawling?

Walking?

Toilet training?

First milk teeth?

First Permanent teeth?

How did your child react to these situations?

Vaccinations:

Birth of a younger sibling:

First day of daycare/school:

Medical

How many rounds of antibiotics has he/she had and for what?

Any skin conditions ever treated with cortisone?

Did he/she suffer from a childhood disease with severe symptoms (measles, chickenpox, croup, mumps, etc?

Mentals

When ill or upset, does he/she tend to cling to you or want to be left alone?

Is your child affectionate when not sick?

Is your child sympathetic (showing concern for the suffering of others or animals)?

Does your child prefer to be alone or with their friends?

How is their behavior when playing with others and does it make a difference if the other kids are younger or older?

When upset, do they tell others or keep it to himself?

Is there any jealousy and in what situations?

Does your child worry and about what?

Are they an anxious child?

Do they cry easily?

How do they express anger?

Are they obstinate and if so how is this expressed?

Fears (darkness, being alone, crowds, heights, flying, elevators, animals, etc.)?

Is your child confident or do they need a lot of reassurance?

Does they tend to be fastidious or messy?

Do they like music? Dancing? Do symptoms such as restlessness improve with music?

Foot and Thirst

Cravings:

Aversions:

Does your child crave sweet, salty, fatty, sour, spicy the most (rank them in order from the most liked to the least liked)?

Are they thirsty? How much does they drink in a day?

What temperature do they prefer their drinks?

Stomach

Any stomach problems?

Sleep

What hour does your child go to bed and how long does it take for them to fall asleep?

Do they tend to wake up at a particular time and why?

Do they do anything in your sleep (speak, laugh, shriek, toss about, grind your teeth, snore etc.)?

Have they ever wet the bed and if so how long was this a problem?

What position does your child sleep in?

Have they had a lot of nightmares?

Do you know if they have ever had any recurring dreams?

Can you tell me of a dream they have had recently?

Sleep

Has your child reached puberty? Any problems?

Have they ever had a problem with masturbation?

Do they tend to have constipation or diarrhea?

Frequency of bowel movements?

Perspiration

Does your child perspire a lot and where?

Generalities

What time of day tends to be their best / worst?

Do they tend to be chillier or warmer than others?

What would you say is unusual or distinctive about your child? (Such as behaviors, fears, fantasies, desires, attachments etc.)

Sensitivity

Is your child sensitive to noises, smells, or touch?

Are they unusually sensitive to criticism or reprimands?

How sensitive on a scale of 1-100 is your child to alcohol, drugs, medications, anesthesia, caffeine, foods?

Homeopathy is considered to be an alternative/preventative system of health care and is not intended to be a substitute for allopathic or traditional medicine.

The therapy and information offered should not be construed by you, the client, or any family, friends or caregivers to be a medical diagnosis of any disease or injury.

You should consult with your physician for any serious medical condition and further, you should get at least two medical opinions for such condition.

While Mohamed El Siddig ,DHMS , DMLS , ( HD) ,CMA member has had extensive training in the science and art of Homeopathy .

Homeopathic Disclosure & Informed Consent

I understand that a homeopathic remedy may be given with this consultation or be suggested for purchase at a store of my choosing.

If given at the time of consult and needed to be repeated before the next consult, a $10.00 remedy fee (plus shipping if necessary) will be charged.

I confirm that any prescription medications I am taking under the care of a physician will not be withdrawn without his/her supervision.

I understand that a block of time has been set aside for my private appointment and that a 24-hour notification is required if I must cancel.

I understand that there is a fee of one consult hour ($50.00) for appointments canceled less than 24 hours in advance.

I understand that payment is due at the time services are rendered, unless other arrangements have been made prior to the appointment.

I understand that phone consultations will be billed at the usual hourly rate.

I understand that current fees for single consultations are as follows, but that there may be changes in the fee structure in the future.

Initial Single Consultations $100.00 (120 minutes)
Follow-up Single Consultations $60.00 (60 minutes)

Homeopathy is considered to be an alternative/preventative system of health care and is not intended to be a substitute for allopathic or traditional medicine.

The therapy and information offered should not be construed by you, the client, or any family, friends or caregivers to be a medical diagnosis of any disease or injury.

You should consult with your physician for any serious medical condition and further, you should get at least two medical opinions for such condition.

While Mohamed El Siddig ,DHMS , DMLS , ( HD) ,CMA member has had extensive training in the science and art of Homeopathy .

I HAVE READ THE ABOVE AND AGREE TO ALL TERMS:

Signature

Do you agree?