Name * First Name Last Name Email * Date of Birth MM DD YYYY Weight (in Kg) Gender Female Male Name of Mother Name of Father Phone Country (###) ### #### Phone (Mother) Country (###) ### #### Phone (Father) Country (###) ### #### Email (Mother) Email (Father) We require the following details about your child’s symptoms. 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. 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, overexposure 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 ? and ? for a detailed list of the factors) Please mention how each factor affects the child whether it increases or decreases his/her complaint, and also how much does it affect child’s complaint. (e.g. headache worse by even little expos Details of past illness of your child Family History (To be filled by the parents only) Father Mother Grandparents (Maternal and Paternal) List of Major Diseases: Anaemia, Cancer, Diabetes, Insanity, Rheumatism, T.B., Pleurisy, Leprosy, Epilepsy, Fits, Bleeding tendency, Urticaria, Eczema, Asthma, Paralysis, Hypertension, Heart trouble Were there any other problems in growth & development of the child? In order to understand the emotional and intellectual nature of the child, we will be asking certain questions. Answer them freely, carefully and completely. This information will help us much in giving the correct remedy. Also such a remedy will help improve mental make up of the child. Thank you! Adult Patient Case Record Form
