Dr Sunil Anand

Pediatric case form

Name:

Age:

Sex:

Vegetarian/Non-veg/Egg/

Education:

School:

Address:

Telephone : Residence:

Mobile:

Referred by:

Office:

Please read this before filling up the form.

You have come to us to regain your health. We are here to help you in the
best possible way by selecting the best possible medicine that will heal your
child at the level of both mind and body. In order to do that, we depend
totally on your co-operation. Homoeopathic medicine is mainly selected on
the basis of the symptoms you give us. If we are to make a successful
prescription, we must know all the details of your childs illness. We must
also understand all the features that belong to him/her as an individual as
well. This includes her/his reactions to various factors, past and family
history and their mental make-up.

This information will enable us to select the right remedy which will help your
child at the level of body and mind.

In order to find out all about them and their illness, we shall be asking you
many questions. Each one of these questions has a definite meaning and
significance for us. There is not a single question that is useless. Even
something that you may think is not connected with their trouble may be the
most important factor in deciding the correct homoeopathic medicine. That is
why you must be free and frank in answering each of these questions in the

utmost of details. Please read each question carefully, think, and if

necessary, consult someone close to you and then answer completely.

To tell or write to a homoeopathic physician, My child has headache,

eruptions, or a cough is not enough. If you inform him that my child gets
headaches with sharp shooting pains, especially in the left side of the head,
more so at night when going to sleep. The pains are much better when the
head is tied up and he/she cannot tolerate fan at all. He/she is irritable with
the pain some much so that she /he strikes at people around her but when
she is not having the complaint she is an angel. In this you have said all you
have to say about the child who is having the headache.

Please avoid replying in a mere yes/no. Give complete details of the

information asked for. Use colloquial language wherever necessary, the
questions are merely suggestive. You may provide any extra information
wherever required.

Do not keep anything back. Remember, whatever you tell us will remain
absolutely confidential

Family information
Details of the family setup

(Detailed information of the familyparents, brothers, sisters including relatives). Provide

information about them in the table provided below.
RELATIONSHIP
PATERNAL GRAND FATHER
PATERNAL GRAND MOTHER
MATERNAL GRAND FATHER
MATERNAL GRAND MOTHER
MOTHER
FATHER
BROTHERS/SISTERS
PATERNAL UNCLES
PATERNAL AUNTS
MATERNAL UNCLES
MATERNAL AUNTS
COUSIN BROTHERS & SISTERS
ON MATERNAL SIDE

ALIVE /DEAD AGE/EDUCATIO DISEASES

N
SUFFERED

CAUSE OF DEATH

COUSIN BROTHER & SISTER ON

PATERNAL SIDE
DID ANY OF YOUR RELATIVES
HAVE SAME TROUBLE/S
SIMILAR TO YOURS

RELATED FAMILY HISTORY:

Genetic diseases:
If any especially in children or close relatives.
Marriage (consanguineous)

MEDICINE HISTORY: (of child)

Details of the same.
Reactions if any.
Currently if on any medications please mention all the details.

VACCINATION HISTORY: Details

Any adverse reactions or change in the behavior after a specific vaccine.
Is there a definite pattern which can be observed? If yes, please give the details of the

same.

PERSONAL HISTORY: (Mother and child)

Medical history during pregnancy? Give details of the same and mention any side effects

observed due to medications, if any.

Mothers history in pregnancy: Any difficulty during conception, any history of

abortions/ torch test being positive. Please make a special mention of the
mental state during pregnancy.
Any history of tobacco/alcohol consumption/substance abuse during pregnancy.
Details of labor. Any post delivery complications. Any history of gestational illness such

as thyroid and diabetes, if others specify?

 Birth difficulties: (give details with respect to ---cry after birth/jaundice/any other

procedures done)
Details of lactation and supplementary feeds exclusive breastfeeding till what age?

When were supplemental foods introduced?

Birth weight Important Milestones

Dentition
Sitting
Standing
Walking
Speaking
Toilet training
Any other difficulties with respect to the growth of the child?
History of animal bites: Dog/ rat/ snake/ scorpion. (Did you take any anti-rabies or anti-

venom or any other treatment for the same?)

DETAILS OF THE MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES

(Please give details of the onset of the illness, its continuation with respect to-

location, complaint/sensation/ aggravation/amelioration/ accompaniments).

In preverbal children, you may mention the sign language

used during the complaints.

With older children, please mention the precise sensation or

language (mother tongue) with respect to the complaints.

Origin/causeCan you trace the origin of the present illness to any particular

circumstances/accidents/illness/incidents/mental upsets (e.g. shock, fright, changes in

diet, exposure to cold/heat etc

APPETITE AND THIRST

How is your appetite?
At what time of the day are you most hungry?
What happens if you have to remain hungry for long?
How fast do you eat?
How much water do you consume (thirst)? (please refer to liquids in any form)
Any particular times of the day are you very thirsty?

Please put on tick () if you like or dislike the food or if the food disagrees, put two ticks () if
you strongly like or dislike.
Likes
Bitter
Salt extra
Burnt/barbecue
foods
Sweet
Sugar
Sour
Bread
Butter
Fast/fried foods

Dislikes Disagree

Likes
Spicy food
Meat
Fish
Cabbage
Onions
Warm foods
Buttermilk(sweet/
salty)
Warm
drinks/tea/coffee
Ice/ice-cream/iced
drinks
Carbonated drinks

Snacks
Cheese
Mud/
chalk/paper/ash
Chocolate
Eggs(fried/boil
ed/hard/soft)

Fruits
Juices
Raw veg/ salads

Vegetables
/raw veg/salads

Specific
condiments/season
ing

Milk
Pickles

Dislikes disagree

Peppermints/
chewing gums

Candies

STOOLS
Do you have any problem regarding stools?
When and how many times in the day do you pass stools?
Is there urgency, if yes, when?
Do you need to strain for stools? Even if soft?
Any complaints of passing gases? Describe its character?
Any history of involuntary stools, when?

URINATION AND URINE

Any difficulty with urination?
Any strong smell of urine? If yes, please describe the same?
Do you have any trouble before, during and after passing urine?
Any difficulty regarding the flow? (slow to start, dribbling, feeble, interrupted etc.)
Any involuntary urination/bedwetting? Since when and details of the same?
Any history of circumcision, reasons for the same?
Is the foreskin tight?

SWEAT AND PERSPIRATION

How much do you sweat?
When / and which part do you sweat most?

 Do you perspire on the palms and soles and when?

Is the sweat warm/ cold/clammy/sticky/stiffens the linen/stains cloth etc?
What does the sweat smell like? (e.g. foul, pungent, sour, urine like/musty etc.)

FACTORS THAT AFFECTS YOU

FACTORS
Hot weather
Cold weather
Cloudy weather
Rainy weather
Change of season
Thunder storm
Covering
Walking
Running
Climbing upstairs
Climbing downstairs
Warm bath
Sun
Cold bathing
Noise
Sudden noise
Music
Open air
Animals/insects

Dancing
Incense
Heights

EFFECT

FACTORS
Light
Urine before
Urine during
Urine after
Touch
Sleep
When angry
Coughing
Sneezing
Laughing
Reading
Writing
After haircut
Combing hair
brushing teeth
When alone
When in family
When in crowd
Outdoors /nature
Travelling
(road/air/sea)
Petrol
Perfumes/Deos
Smells(pleasant/unplea
sant)
.

SLEEP

EFFECT

 Describe your posture in sleep: e.g. on the back, sides, abdomen, knee-chest etc.
Do you sleep in any specific position, in which position sleep is impossible?
Is there a need for body contact?
DURING SLEEP DO YOU: Walk/Grind teeth/ Snore/Dribbles saliva/Keep eyes or mouth

open
Talk/ moan/Weep:
Do you experience any nightmares?
Do you have abrupt sleep/ startling from sleep with fear/palpitations?
How much covering do you use?
Do you need to uncover any parts?
DREAMS: If any please give details of the same

MIND
Does he /she get anxious? About which matters?
Is he /she fearful of anything? If yes please give details of the same with respect to the

change in behavior. Any incidence which set off the fear and its effects of the same.
Behavioral details: Patterns if any e.g. frequent hand or body washing/breath holding

spells/temper tantrums?
Nail biting? Is it associated with any incidences? Is there any bleeding/pain associated

with it.
Does he/she have the habit of thumb sucking? When does she prefer to do it?
Any sibling rivalry?
Reactions to reprimands/punishments?

Please mark tick () he/she likes to prefer or react or play, and mark two tick () if strongly.
Silent
Active
Violent/Abusi
ve
Harsh/rude
Hyperactive
Reserved
Shy
Timid
Sympathetic
Crowd
Being alone
Color
preferences
Music
soft/rock
Stage
performance

Strangers
Soft toys
Games(indoor)
Games(outdoor)
Gadgets/video
games
Pet animals
Open air
Instruments
In room
Any other
Imitation/mimicr
y
Jokes /Quiz
Leadership
quality

What kind of programs does the child like?

Creative area: Drawing, Random scribble or doodle (any repetitive pattern)? please draw

the same for our records.

Infants: Any repetitive activity, signs the child is using / can be observed please give

details of the same.

Small children (1-4 years): Please give the details of the childs play pattern.
State the strengths and weaknesses of your child with respect to his/her qualities, areas of

work, play etc.

 How does your child deal with the

Concept of money
Responsibility
Reprimands/punishments
Leadership roles
Failures/competition
Physical activities(competitive sports)
Career choices/fascination for any specific characters e.g. super-heroes, role

models, athletes, magician etc.

Details of the academic progress - Any learning difficulties, if any since when?
What are the different methods of remediation adopted being used for the same?
Any physiotherapy or occupational therapy being used/ please give details of the same?

I UNDERSTAND THAT MY CASE INTERVIEW MAY BE RECORDED/ON VIDEO FOR

THE PURPOSE OF STUDY AND TEACHINGS. I GIVE MY CONSENT TO THE SAME.

SIGNATURE