CHILD INTAKE FORM

CHILD INTAKE FORM
Date form completed*

DayMonthYear
Child's Name*

First NameLast Name
Date of Birth (please write day - month - year)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/GuardianPhone Number*
Parent/Guardian e-mail*
Name of GP
GP Phone Number
GP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Does your child have any siblings? Please note their ages if so.
PRESENTING CONDITION
What has brought you for homeopathic treatment?*
when did it START?
are there any factors that may have CONTRIBUTED to the ONSET of their condition?
are there any other SYMPTOMS or SENSATIONS that they experience?
PREGNANCY & LABOUR
were there ANY DRUGS NEEDED by mother during pregnancy? or any other INTERVENTIONS?
was the pregnancy FULL TERM?
was CONCEPTION natural or IVF?
any AILMENTS, STRESSES, INJURIES etc. during pregnancy?
MEDICAL HISTORY
BIRTH WEIGHT
any CRADLE CAP?
any NAPPY RASH?
any current or past MEDICAL CONDITIONS including jaundice, reflux, any known allergies etc
SURGERY or MEDICAL PROCEDURES?
any current or past MEDICATIONS? Please include steroids, antihistamines, antibiotics & so on with ages/dates if known.
any VACCINATIONS? Please note age/dates if known
any reactions to VACCINATIONS or any MEDICAL DRUGS?
How is your child's ORAL HEALTH? Please note any DENTAL WORK.
Does your child have or have they ever had any METAL AMALGAM fillings?
any INJURIES? including falls on to the coccyx, broken bones, concussion etc
any BLOOD TRANSFUSIONS
any IMPLANTS including pins, plates or dental implants? Please detail if so.
FAMILY MEDICAL HISTORY
FAMILY HISTORY of cancer, diabetes, rheumatoid arthritis, heart disease, alcoholism, depression etc.*
GENERALS & PHYSICALS
Do they eat MEAT? If so, what is their preference ie. fish, pork, beef, chicken?
What are their lifelong FAVOURITE FOODS?
Do they have a SWEET tooth?
Do they like SALTY foods?
Do they like SOUR foods ie. lemon, vinegar?
Are they generally THIRSTY? if so what do they tend to drink - water, fizzy drinks, juice etc?
How would you describe their THERMAL state? ie. tendency to be chilly, warm, hot, warm body cold extremities etc?
Can you describe their SLEEP? Do they fall asleep easily or does it take time? Do they wake through the night? DREAMS or NIGHTMARES? How are they when they WAKE IN THE MORNING?
TRAUMA
are there any major TRAUMATIC EVENTS that they have experienced? including during pregnancy/labour, birth of siblings, house moves, school moves, injuries, parental stress etc.
FEMALES
Has your child started her PERIOD? If so at what age did this start?
Are there any symptoms experienced around menstruation to note?
FOR THE CONSULTATION
would you like to add anything else that is relevant?
are there any issues that you would prefer to discuss in person and not in the presence of your child?
GENERAL INFORMATION
Do you have a Homeopathic First Aid kit at home?

yesno
How did you hear about Pailin Brzeski?
Consent to Homeopathic Treatment

I confirm that I request homeopathic treatment and understand the need to seek appropriate medical diagnosis and treatment in the usual way.
I can confirm that I request homeopathic treatment for my child.*

YesNo
I understand the need to seek appropriate medical diagnosis and treatment in the usual way.*

YesNo
I understand that Pailin Brzeski will prescribe homeopathic medicines according to the laws of the United Kingdom.*

YesNo
Parent / Guardian Signature*
SIGNED ON DATE (day - month - year)*
This form will be printed as a hard copy and placed in a locked filing cabinet.
All electronic versions will then be immediatly deleted.
Should be Empty:

CHILD INTAKE FORM

PRESENTING CONDITION

PREGNANCY & LABOUR

MEDICAL HISTORY

FAMILY MEDICAL HISTORY

GENERALS & PHYSICALS

TRAUMA

FEMALES

FOR THE CONSULTATION

GENERAL INFORMATION

Consent to Homeopathic Treatment