Child Patient Case Form

You can fill the case form offline by downloading the English offline form – click here

OR fill the case form online below:

 
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Occupation of Parents (Nature of Work)

Address of Work Place

Details of present illness

In Homoepathy, prescription is based on precise details of various complaints that the child has, mere mention of a complaint does not suffice for a good prescription. Please follow the instructions given below for helping us understand your child’s complaints. We require the following details about your child’s symptom.
Express the type of sensation or the pain that he / she get in his / her own words however simple or funny it may seem. Express the sensation or pain as it feels to him / her. Be free describe the pain and his /her experience with the same in child’s own words.
Can you trace the origin of the present illness to any particular circumstance, accident, illness, incident or mental upset? (e.g. Shock, worry, errors in diet, obverexertion to cold, heat etc.)

Part & Family History

Vaccination History

Family History

Information about child's siblings

Development History

At what age did the child start

Personal History

Appetite and Thirst

Urination & Urine

Stool

Sweat / Perspiration - Fever - Chill

Sleep

Sensitivity to heat and cold

Sexual Sphere (General)

Mind

In order to understand you we will be asking certain questions. Answer them freely, carefully and completely. This information will help us much in giving you the correct remedy. Also such a remedy will help improve your mental make up. Answer freely. Answer frankly. Answer completely.
Click or drag a file to this area to upload.

Parts of body affected

Mother's history during pregnancy

Any change your observed in your general pattern of

Delivery History

Click or drag files to this area to upload. You can upload up to 20 files.

The information that you submit will be handled as per our privacy policy.