1 Pediatric Case Form

8/10/2019 1 Pediatric Case Form

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Dr Sunil Anand

Pediatric case form

Name:

Age: Sex:

Vegetarian/Non-veg/Egg/

Education: School:

Address:

Telephone : esidence: !"ce:

#o$ile:

eferred $%:


2/23

Please read this $efore &lling up the form'

(ou have come to us to regain %our health' )e are here to help %ou in the$est possi$le *a% $% selecting the $est possi$le medicine that *ill heal %ourchild at the level of $oth mind and $od%' +n order to do that, *e dependtotall% on %our co-operation' omoeopathic medicine is mainl% selected onthe $asis of the s%mptoms %ou give us' +f *e are to ma.e a successfulprescription, *e must .no* all the details of %our child s illness' )e mustalso understand all the features that $elong to him/her as an individual as*ell' This includes her/his reactions to various factors, past and famil%histor% and their mental ma.e-up'

This information *ill ena$le us to select the right remed% *hich *ill help %ourchild at the level of $od% and mind'

+n order to &nd out all a$out them and their illness, *e shall $e as.ing %ouman% 0uestions' Each one of these 0uestions has a de&nite meaning andsigni&cance for us' There is not a single 0uestion that is useless' Evensomething that %ou ma% thin. is not connected *ith their trou$le ma% $e themost important factor in deciding the correct homoeopathic medicine' That is*h% %ou must $e free and fran. in ans*ering each of these 0uestions in the


3/23

utmost of details' Please read each 0uestion carefull%, thin., and ifnecessar%, consult someone close to %ou and then ans*er completel%'

To tell or *rite to a homoeopathic ph%sician, 1#% child has headache,eruptions, or a cough is not enough' +f %ou inform him that m% child getsheadaches *ith sharp shooting pains, especiall% in the left side of the head,more so at night *hen going to sleep' The pains are much $etter *hen thehead is tied up and he/she cannot tolerate fan at all' e/she is irrita$le *iththe pain some much so that she /he stri.es at people around her $ut *henshe is not having the complaint she is an angel' +n this %ou have said all %ouhave to sa% a$out the child *ho is having the headache'

Please avoid repl%ing in a mere %es/no' 2ive complete details of theinformation as.ed for' 3se collo0uial language *herever necessar%, the0uestions are merel% suggestive' (ou ma% provide an% extra information*herever re0uired'

Do not .eep an%thing $ac.' emem$er, *hatever %ou tell us *ill remaina$solutel% con&dential


4/23

4amil% information

Details of the family setup

(Detailed information of the familyparents, brothers, sisters including relatives). Provideinformation about them in the table provided below.

RE !"#$%&'#P ! # E DE!D !*E ED+ !"#$ %

D#&E!&E&&+--ERED

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P!"ER%! *R!%D -!"'ER P!"ER%! *R!%D $"'ER

!"ER%! *R!%D -!"'ER !"ER%! *R!%D $"'ER $"'ER

-!"'ER /R$"'ER& &"ER&P!"ER%! +% E&P!"ER%! !+%"&

!"ER%! +% E&!"ER%! !+%"&$+% /R$"'ER& 0 &"ER&

$% !"ER%! DE


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$+% /R$"'ER 0 &"ER $%P!"ER%! DED#D !%1 $- 1$+R RE !"# E&'! E &! E "R$+/ E & # !R "$ 1$+R&

RE !"ED -! # 1 '#&"$R12

*enetic diseases2

#f any especially in children or close relatives.

arriage (consanguineous)

ED# #%E '#&"$R12 (of child)

Details of the same.

Reactions if any.

urrently if on any medications please mention all the details.

! #%!"#$% '#&"$R12 Details

!ny adverse reactions or change in the behavior after a specific vaccine.

#s there a definite pattern which can be observed3 #f yes, please give the details of thsame.

PER&$%! '#&"$R12 ( other and child)

edical history during pregnancy3 *ive details of the same and mention any side effecobserved due to medications, if any.

other4s history in pregnancy2 !ny difficulty during conception, any history ofabortions torch test being positive.Please ma.e a special mention of themental state during pregnanc%'

!ny history of tobacco alcohol consumption substance abuse during pregnancy.

Details of labor. !ny post delivery complications. !ny history of gestational illness suchas thyroid and diabetes, if others specify3


6/23

/irth difficulties2 (give details with respect to 555cry after birth 6aundice any other procedures done)

Details of lactation and supplementary feeds 7e8clusive breastfeeding till what age3

9hen were supplemental foods introduced3/irth weight5

#mportant ilestones

Dentition

&itting&tanding9al:ing&pea:ing"oilet training

!ny other difficulties with respect to the growth of the child3

'istory of animal bites2 Dog rat sna:e scorpion. (Did you ta:e any anti5rabies or avenom or any other treatment for the same3)


7/23

DETA+5S !4 T E #A+N 6!#P5A+NTS AND !T E ASS!6+ATED T !375ES

8Please give details of the onset of the illness, its continuation with respect to5location, complaint sensation aggravation amelioration accompaniments).

+n prever$al children, %ou ma% mention the sign languageused during the complaints'

)ith older children, please mention the precise sensation orlanguage 8mother tongue9 *ith respect to the complaints'

$rigin cause an you trace the origin of the present illness to any particularcircumstances accidents illness incidents mental upsets (e.g. shoc:, fright, chan

diet, e8posure to cold heat etc


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9/23

Peppermintschewing gums

andies

&"$$ &

Do you have any problem regarding stools3

9hen and how many times in the day do you pass stools3

#s there urgency, if yes, when3

Do you need to strain for stools3 Even if soft3

!ny complaints of passing gases3 Describe its character3

!ny history of involuntary stools, when3

+R#%!"#$% !%D +R#%E

!ny difficulty with urination3

!ny strong smell of urine3 #f yes, please describe the same3

Do you have any trouble before, during and after passing urine3

!ny difficulty regarding the flow3 (slow to start, dribbling, feeble, interrupted etc.)

!ny involuntary urination bedwetting3 &ince when and details of the same3

!ny history of circumcision, reasons for the same3

#s the fores:in tight3

&9E!" !%D PER&P#R!"#$%

'ow much do you sweat3

9hen and which part do you sweat most3


10/23

Do you perspire on the palms and soles and when3

#s the sweat warm cold clammy stic:y stiffens the linen stains cloth etc3

9hat does the sweat smell li:e3 (e.g. foul, pungent, sour, urine li:e musty etc.)

-! "$R& "'!" !--E "& 1$+

-! "$R& E--E " -! "$R& E--E "'ot weather ight

old weather +rine 7 beforeloudy weather +rine 7 during

Rainy weather +rine 7 afterhange of season "ouch

"hunder storm &leepovering 9hen angry

9al:ing oughingRunning &nee>ing

limbing upstairs aughinglimbing downstairs Reading

9arm bath 9riting&un !fter haircut

old bathing ombing hair %oise brushing teeth&udden noise 9hen alone

usic 9hen in family$pen air 9hen in crowd!nimals insects $utdoors nature

"ravelling(road air sea)

Dancing Petrol#ncense Perfumes Deos'eights &mells(pleasant unplea

sant)

.

S5EEP


11/23

Describe your posture in sleep2 e.g. on the bac:, sides, abdomen, :nee5chest etc.

Do you sleep in any specific position, in which position sleep is impossible3

#s there a need for body contact3

D+R#%* & EEP D$ 1$+2 9al: *rind teeth &nore Dribbles saliva ?eep eyes or moopen

"al: moan 9eep2

Do you e8perience any nightmares3

Do you have abrupt sleep startling from sleep with fear palpitations3

'ow much covering do you use3

Do you need to uncover any parts3DRE! &2 #f any please give details of the same

#+ND

Does he she get an8ious3 !bout which matters3#s he she fearful of anything3 #f yes please give details of the same with respect to tchange in behavior. !ny incidence which set off the fear and its effects of the same.

/ehavioral details2 Patterns if any e.g. fre;uent hand or body washing breath holdingspells temper tantrums3

%ail biting3 #s it associated with any incidences3 #s there any bleeding pain associatwith it.

Does he she have the habit of thumb suc:ing3 9hen does she prefer to do it3!ny sibling rivalry3

Reactions to reprimands punishments3


12/23

Please mar: tic: (


13/23

'ow does your child deal with the 7

oncept of money

Responsibility

Reprimands punishments

eadership roles

-ailures competition

Physical activities(competitive sports)

areer choices fascination for any specific characters e.g. super5heroes, rolemodels, athletes, magician etc.

Details of the academic progress 5 !ny learning difficulties, if any since when39hat are the different methods of remediation adopted being used for the same3

!ny physiotherapy or occupational therapy being used please give details of the same


14/23

# +%DER&"!%D "'!" 1 !&E #%"ER #E9 !1 /E RE $RDED $% #DE$ -$R"'E P+RP$&E $- &"+D1 !%D "E! '#%*&. # *# E 1 $%&E%" "$ "'E &! E.

*%!"+RE


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Documents

1 Pediatric Case Form