Child New Patient Form - Classic Homeopath Registration

Child New Patient

Please allow 30 minutes to complete this detailed new patient form. Please fill out as thoroughly as possible and do not leave any fields blank. The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.

Child's Full Name *

Mother's Full Name *

Father's Full Name *

Parent's Email Address *

Primary Phone *

Mother's Phone *

Father's Phone *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Child's Date of Birth *

Month

Day

Year

Referred by *

Gender *

Emergency Contact Person *

Emergency Contact Phone *

Siblings ages and names *

Current School and Grade Level *

Birth HistoryPlease include birth weight and any problems during pregnancy or after birth.

Medical History

Hospitalizations: Give the following information for the last three times your child has been hospitalized starting with the most recent. Include type of illness, month and year hospitalized, name of hospital, city and state.Illness, Date, Hospital, Location.

AllergiesFoods, pets, pollens, molds, chemicals, medications, etc.

Current MedicationsType, dosage, frequency.

Currently used medicinal herbs, vitamins, teas.Name, dosage, frequency.

Homeopathic Remedies used/usingName, potency, frequency.

Your Child's Personality and Preferences

Describe an ideal day for your child in terms of weather and temperature

What are they most sensitive to? (eg. noise, odors, light, pain)

What are his/her fears?

Does he/she have any hobbies?

(Girls only) What symptoms do she experience premenstrually?

Describe any recurrent dreams, important dreams in their life or recurrent themes in your dreams

How is their energy? Is there any particular time of day when it is lower or higher?

What environment do they feel most comfort in? (IE desert, mountains, ocean, city)

What do they most like to eat or crave?

What is their favorite color?

What foods do they most dislike?

How is their thirst?

What temperature do they like fluids?

Are there any foods that they are sensitive to or allergic to?

Family History

Highlight all relatives with a history of this illness.

Questions, Comments, or Additional Information

Upload pictures, close up, full-length and candid, as well as any areas of concern (skin, etc.) Or email to tina@classichomeopath.com

Upload images of any art, drawings, writing, or any other creative activity and/or hobbies. Or email to tina@classichomeopath.com

Notice

The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.

Child Registration Form