Two Legs and Four Holistic Health Adult Questionnaire

Two Legs and Four Holistic Health - Child Questionnaire (0-10 years)
Date*

MonthDayYear
Mother's name*

First NameLast Name
Father's name*

First NameLast Name
Child's name*

First NameLast Name
DOB of Child*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Landline Phone

Area CodePhone Number
Cell/Mobile Phone

Area CodePhone Number
E-mail*
Connecting for consultation*

Brave (online)Visit to clinic
How did you hear about me

Internet searchReferral by extended family memberReferral by friendAlready treating a close family memberOther
If other, please detail
Your Child's Health Concerns
Place of birth of child
Describe your child's chief complaint with details.*
How does this condition impact their life?
Are there any factors which influence your child's health?
Please detail any other complaints or concerns.
How do they impact their life?
Please list any drugs used*

AntibioticsAntihistaminesCortisone/steroidsInhalerOtherNone
Please elaborate on dosage, duration and repetition
Please indicate past drug use, duration and repetition*
Please list any health or dietary supplement used
Conception, Pregnancy, Delivery

Please provide details

Please think back carefully to that time.*


Was the child conceived while using a contraceptive?
Was the child planned?
Was IVF used?
How long did it take to conceive?
Was surrogacy used?
Were there any medications used in pregnancy?
Were any vaccines administered in pregnancy?
Was there morning sickness?
If so, for how long?
Was the birth at home or hospital?
Was an epidural used?
Was the birth induced?
How long was the labour?
Was suction or forcepts used?
Was the birth a C section?
Was there a problem with baby's position?
Was there significant blood loss?
What was the birth weight?
Was the baby breast fed?
How long for?
Who instigated weaning - mother or child?
Was the birth full term?
Other

Please elaborate on changes, circumstances, feelings, thoughts, fantasies, etc
What were your dreams during the pregnancy?
Was there an incident that profoundly affected you?
Did you have any food cravings or aversions, likes or dislikes, intolerances, etc?
Growth, Development, Milestones

Please detail*

	Age	Any problems
Holding head up
Crawling
Teething
Sitting
Standing
Walking with support
Walking without support
Speaking
Potty trained
Other

Any comments
Your Child's History and Family History
Please detail any operations or surgeries and the mode of anaesthetic - local or general.*
Any comments and familial tendencies in extended family members
Environment

Check all the factors that apply to your child's current life
Are they adversely affected by

SeasonsHigh temperatureHumidityCold temperatureChange in weatherChange in temperatureWindThunderstormsPhases of the moonStuffy or warm roomsSmokeThe sunCloudy weatherDry weatherOther
Any comments
Drug History

Drugs used in life*

	Date	Date	Date	Date	Date	Date
Antibiotics
Steroids/cortisone
Inhalers
None
Other
Other
Other

Any comments
Sleep, Dreams

Sleep*


Is there difficulty falling asleep?
Do they wake frequently in the night?
Do they sleep well?
Do they snore?
Do they grind their teeth?
Do they sleep walk?
Do they sleep talk?
Do they have nightmares?
How are they on waking in the morning?
What position do they sleep in?
Do they like to be warm or cool in bed?
Do they like a window open or fan on even in cool weather?

Any comments
Food, Thirst, Digestion

Food, Thirst*


How is the appetite?
How is the thirst?
What happens if they remain hungry for long?
Do they eat fast/slowly?
How easily are they satisfied?
How often are they thirsty?
How much do they drink at a time?
Other

Please elaborate

Digestion*


Do they have trouble with digestion?
If so, what?
Do they bloat, burp or pass gas?
How often do they have a bowel movement?
Do they have to strain?
Other

Any comments

Urination*


Do they have a urinary tract issue?
If so, what?
Does the urine have a stronger than normal smell?
Does the urine have a deeper than normal colour?
Is there any pain on urination?
Is the flow slow to start or interrupoted?
Is there any involuntary urination?
Is there crying before, during or after urination?
Is there bed wetting?

Any comments

Stool*


Is there a bowel issue?
How often is a stool passed?
Are they satisfied after a bowel movement?
Is there straining?
Is there constipation?
Is there diarrhoea?
Is it urgent?
Is there crying before, during or after stool?
Other

Any comments
Mind, Emotions, Activities, Hobbies
What is the child's nature?
Describe the experience of the child in stressful situations.
What are their fears?
Has there been an incident that strongly affected them?
What are their favourites activities?
What do they like to draw or colour in?
How different is your child that sets them apart from others.
Do they have any ambitions, already know what career they want later in life?
What is the relationship with family, teachers, other children?
What do they do when alone?
What are your wishes for the child?
What are your expectations?
Please elaborate
Thank you!

CONGRATULATIONS in completing this marathon questionnaire! This is a significant step in your child's journey to wellness.
If your child has seen another homeopath, please detail the remedies and the effect
If you have used homeopathic remedies on your child, please detail the remedies and the effect.
Re-scheduling, Privacy
Re-scheduling or Cancellations

Homeopathic consultations take time. My appointments are lengthy to discover the core reason for your ill health. So cancellations or failure to make an appointment makes a big impact on my day. Inevitably there are times where you need to re-schedule your appointment. Wherever it is possible, I do appreciate you giving me as much notice as possible, at least 24 hours is preferred. Often, people ring me early in the day for an appointment and it is frustrating for us both when there is apparently no free slot, which ultimately becomes available.Those who fail to attend to a prearranged appointment or don’t give me 24 hour advance notice may be charged for the full consultation. I appreciate your consideration.
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Two Legs and Four Holistic Health - Child Questionnaire (0-10 years)

Your Child's Health Concerns

Conception, Pregnancy, Delivery

Growth, Development, Milestones

Your Child's History and Family History

Environment

Drug History

Sleep, Dreams

Food, Thirst, Digestion

Mind, Emotions, Activities, Hobbies

Thank you!

Re-scheduling, Privacy

Re-scheduling or Cancellations