Child Patient Case Form – Dr. Sankaran's Clinic

93222 65836

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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:

Name *

Date of Birth *//

Age

Sex

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Nationality

Residence Number

Mobile Number (Father)

Mobile Number (Mother)

Email (Parent/Guardian) *

Diet

Name of school

Education

Occupation of Parents (Nature of Work)

Father

Mother

Address of Work Place

Father

Telephone Number

Mother

Telephone Number

Referred to us by

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.

What are the complaints?

Since when is the child having these complaints?

Location : Please give the exact location of sensation, pain or eruption. Also describe where the pain or sensation spreads

Sensation

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.

Origin of cause

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.)

What are the factors that influence your child’s health? e.g. Weather, food, pressure, anxiety etc. or any other (please refer to part 4 on page 16 and 17 for a detailed list of the factors) Please mention how each factor affects the child’s whether it increases or decreases his/ her complaint, and also how much does in affect child’s complaint. (e.g. headche worse by even little exposure to sun, heachache better by pressing the head)

Part & Family History

Tick all the major illness so far

Diseases suffered from

Approximate age

Duration

Whether you completely recovered

Medicines & treatment taken

Any other particulars

Diseases suffered from

Approximate age

Duration

Whether you completely recovered

Medicines & treatment taken

Any other particulars

Diseases suffered from

Approximate age

Duration

Whether you completely recovered

Medicines & treatment taken

Any other particulars

Diseases suffered from

Approximate age

Duration

Whether you completely recovered

Medicines & treatment taken

Any other particulars

Diseases suffered from

Approximate age

Duration

Whether you completely recovered

Medicines & treatment taken

Any other particulars

Any extra remarks or information Mention any drugs, tonics, stimulants etc. that have been used by you at any time in life

Vaccination History

Vaccine given

Age

Complaints after vaccination

Duration (for how long did they last)

Any other particulars

Vaccine given

Age

Complaints after vaccination

Duration (for how long did they last)

Any other particulars

Vaccine given

Age

Complaints after vaccination

Duration (for how long did they last)

Any other particulars

Vaccine given

Age

Complaints after vaccination

Duration (for how long did they last)

Any other particulars

Vaccine given

Age

Complaints after vaccination

Duration (for how long did they last)

Any other particulars

Family History

List of major diseases

Anaemia
Cancer
Diabetes
Insanity
Rheumatism
T.B.
Pleurisy
Leprosy
Epliepsy
Fits
Bleeding tendency
Urticaria
Eczema
Asthma
Paralysis
Hypertension
Heart trouble
Kidney diseases
Liver diseases

Who suffered from which diseases?

Information about child's siblings

Sibling's Name

Alive/Dead

Age

Sex

Diseases Suffered

Sibling's Name

Alive/Dead

Age

Sex

Diseases Suffered

Sibling's Name

Alive/Dead

Age

Sex

Diseases Suffered

Sibling's Name

Alive/Dead

Age

Sex

Diseases Suffered

Development History

At what age did the child start

Head holding

Problems

Sitting

Problems

Standing

Problems

Walking with support

Problems

Walking without support

Problems

Teething

Problems

Speaking

Problems

Urine control

Problems

Were there any problems in the growth & development of the child?

Personal History

Does the child suffer from any allergic conditions ? If yes, please specify

Also mention the items that you feel the child is allergic to

If any specific allergic testing is done, then please mention and attach your investigation reports

What substances is / was the child addicted to like internet, games, shopping, any drug substances. Is the child habituated to TV, games, internet, shopping or any other?

Appetite and Thirst

How is the appetite?

When is the child most hungry?

What happens if he / she have to remain hungry for long?

Does he / She have a habit of eating fast?

How easily does he /she feel full after eating? (e.g. soon / eating a lot etc.)

How much thirst does the child have?

How frequently does he / she drink and how much?

Any particular time that he /she especially thirsty?

Does he / she crave for cold / warm water / ice?

Salty food

Bitter food

Spicy food

Sour food

Sweet food

Exotic food

Bread

Butter

Eggs

Chicken

Red Meat

Pork

Fish

Fatty food / Fried food

Cabbage

Onion

Tea

Coffee

Milk

Curds

Buttermilk

Fruits

Warm food

Cold food

Ice

Ice-cream

Cakes / Pastry

Chocolate

Cheese

Any other

Urination & Urine

Any problem about urine?

Any strong smell? Like what?

Do you have any trouble before, during and after passing urine?

Any difficulty about the flow? Slow to start, interrupted, feeble, dribbling etc.?

Any involuntary urination? When?

Stool

Is there any problem regarding stools?

Sweat / Perspiration - Fever - Chill

How much does he / she sweat?

On what part does he / she sweat the most?

Does the sweat smell? What is the kind of smell?

Does the sweat stain he clothes? What colour?

Is there perspiration on the palms or soles?

Sleep

Describe what the posture is during sleep? (E.g. on back, abdomen, sides)

How is the sleep pattern?

Is the child able to sleep in any position? In which position is he / she uncomfortable?

During sleep does the child

Grind teeth
Dribble saliva
Sweat
Keep eyes or mouth open
Walk
Talk
Moan
Weep
Become restless
Wake up with a jerk

Describe if anything unusual about the sleep

How much does he / she cover/uncover any parts?

Check types of dreams that the child has

If any other specify below

Sensitivity to heat and cold

Which season does the child like?

Which weather can he / she not tolerate?

Sexual Sphere (General)

Does the child masturbate? What is the frequency? What is its effect?

Any history of sexual abuse?

Did the child ever suffer from any infection of the genital organs?

Any problem in the genital organs?

Any dryness, itching, discomfort, bleeding, burning or pain in vagina?

At what age did the menses start?

How are the periods; regular or irregular?

How many days is her monthly cycle?

Was there any complaint when the menses first began?

Duration (days) : How long the menses last?

How much is the flow of flow (E.g. profuse, scanty, moderate)

What is the color of the flow?

Do the menses stain? If yes, what is the color?

Are the stains difficult to wash?

Are there any complaints before, during or after menses? If so, describe

Is there any white discharge? If yes, mention the quantity, color, consistency and smell of discharge

When and under what circumstances is it more or less?

Does the discharge have any relation to menses?

Is there any complaint due to discharge? (E.g. itching, burning, discomfort or any other)

Any trouble with breasts?

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.

What is the effect of main complaint and associated complaints on the child?

Describe the unusual sensation they experience during stressful situations like nightmares, fears, before exam, with the incident

What are his / her fears (existing and / or imaginary)?

Any incident which had a deep impact on him / her ? Describe in detail

What are the stories / fairytales that he / she likes to read / listen to?

What are his / her imaginations / fantasies? Describe in detail

What dream does the child gets or had?

What are the nightmares that he / she gets?

What are his / her interests and hobbies?

Describe about the specific toys, games / specific TV serials, cartoon characters, movies the child likes

How is he / she at sports and other activities?

Describe about the drawing and coloring he / she likes

What are the other activities the child likes to?

Describe all the qualities of your child, which makes him / her different from other children, which is unique to him / her

What does he / she wants to become when he is grown up and why? What are his / her ambitions?

Whom does he / she idealize (and why?). What is about him that he /she admires the most?

How his / her behavior with parents, teachers, friends relatives? What are the qualities he / she admires in them?

How his/her behavior in school and what is his / her teacher’s opinion about the child?

What kind of questions does him/ she asks to his / her parents, relatives and teachers?

What are his / her views about the city, state, country and world?

What makes the child cry or laugh?

What makes your child very angry and irritable?

What does the child do when he /she is alone?

What are your child’s five wishes?

Tick the qualities that your child or you as child had

Obstinacy
Unusual fears
Temper tantrums
Shyness
Disobedience
Unusual attachments
Aggression
Hyperactivity
Biting nails
Destructiveness
Thumb-sucking
Courage
Possessiveness
Competition - winning spirit
Picking and playing with shawls, handkerchieves
Picking and playing with mother’s body parts
Picking and playing with anything else
Slibling jealousy
Any special skills
Religious
Unusual desires
Dullness of memory
Boasting
Slowness
Stealing
Laziness / Indolence
Telling lies
Sensitive / Emotional

Unusual attachments to whom?

Slowness in what?

Unusual desires for what?

Please tell the child to draw something which comes to his / her mind at this very moment, Doodles

Click or drag a file to this area to upload.

Parts of body affected

Does your child have giddiness - vertigo?

Does he/she ever feel faint? When?

Does the child get headaches?

Eyes & Vision: e.g. redness, burning, difficulty in reading, etc.

Ears & Sense of Hearing: e.g. ear pain, difficult hearing etc.

Nose & Sense of Smell: e.g. bleeding from the nose, any problem with smell etc.

Face & Facial Expression: e.g. acne, pigmentation, moles, warts etc.

Mouth: e.g. ulcers, bad smell from mouth etc.

Teeth & Gums: e.g. carries in teeth, stained teeth, bleeding or swollen gums.

Tongue & Sense of Taste: any cracks, coating etc.

Lips: cracked, peeling of skin etc.

Throat (including tonsils): e.g. pain, difficulty in swallowing, trouble with voice or speech etc

Cold & Cough: Does the child catch cold often? What factors generally bring on the cold?

Describe the symptoms during cold, nature of discharge from nose etc.

Does he/she get cough? What brings on the cough?

Is it more at any particular time?

Breathing: Any difficulty in breathing?

How frequent is it?

What brings it on or makes it worse/better?

Back & Limbs: Does the child have any trouble in back, limbs or joints? Describe in detail?

If there are pains, do they extend in any direction or shift?

What brings on the pains or makes them worse/better?

Is there any abnormality, swelling, numbness, paralysis etc. in any part of the body?

Skin: Does the child have complaints like itching, eruptions, ulcers, corns, peeling, change in color, spots etc.? If yes, describe

Nails: Is there any complaint or abnormality of the nails or the skin around?

Hair: Is there any complaint with the hair such as falling, graying, dandruff, dryness, oily, poor/excessive/ unusual growth?

General: Do the wounds take a long time to heal?

Does the child has a any tendency to bleed?

Is there any trembling? When?

Is there any sense of weakness? Where?

When is it more and what causes it?

Mother's history during pregnancy

Was the pregnancy planned, unplanned?

Describe the circumstances around the period of conception? (Stressful if any)

Dreams during your pregnancy including around the time of conception

What changes you have observed within you?

Tell the changes you noticed in your nature and behavior from the time you conceived till you delivered the child

Anything unusual or perculiar phenomena you observed only during pregnancy that you think were not a part of your routine nature and that occured with the pregnancy?

Any incident during pregnancy that had a deep impact on you? Describe your feelings, thoughts or any sensation associated with it

What were your dreams during pregnancy? Did you have any unusual, recurrent dream that had a deep impact on you ?

What were the thoughts, fantasies and imaginations about your child during pregnancy?

Did you have any unusual thoughts during that period? Describe in detail. What was your reaction to that?

Did you experience any unusual bodily sensation / movement during this period? Describe the whole experience

Did you have any fear or nightmares during this period? Describe it

Was there any changes in your interests and hobbies during pregnancy?

Did you observe any change in your relationship with people during this period? What was it?

What was the chages in the likes / dislikes for any particular food?

Was there any chages in your sensitivity to heat / cold during preganancy?

Any change your observed in your general pattern of

Thirst

Appetite

Perspiration

Sleep

Bowel movements

Urination

Sexual desire

Did you suffer from any disease during pregnancy?

Were you on / any medication during pregnancy?

Any addiction during pregnancy?

Delivery History

Was it normal?

Was the delivery full term / early / delayed?

Was it Caesarian section / forceps / vacuum delivery? Any other procedure done?

Please attach all medical reports from physicians consulted and opinion on your child’s state of health? Recent copies of investigations done, e.g. C.B.C., ESR, U.S.G., X-ray plates etc.

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

Please mention if your child has taken any Homoeopathic Medicine. Brief us with the name of the medicine he / she has received along with his / her response to the same. (If you are aware of)

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

Where healing is a blessing…

Get in Touch

[email protected]
+91-9322265836
G-3, Beach Haven 1, Wing 1, Near Ramada Inn Palmgrove Hotel, Juhu Tara Road, Mumbai 400049 India.

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