Confidential Patient History--Children

Child’s Name___________________________________Date__________________
Parent/Guardian______________________________________________________
Address_____________________________________________________________
Town/City______________________________State__________Zip_____________
Home Phone_______________________Work Phone________________________
Cell Phone________________________E-mail______________________________
Date of Birth_______________________Age______________Male/Female (circle one)
Siblings—names/ages___________________________________________________
Parents:___Married___Divorced___Separated___Remarried___Never Married___Other
Referred by___________________________________________________________
Current Medical Doctor__________________________Phone___________________
Other Healthcare Providers_______________________Phone___________________
Have you or your child ever seen a Homeopath before?         ______yes   _______no

Pregnancy/Labor: (Briefly list any notible complications/difficulties; we will review this more in depth in consultation):_____________________________________________
_____________________________________________________________________
_____________________________________________________________________
Child’s history of hospitalization, surgery or illness: (Please include dates)
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medication--Current:____________________________________________________
_____________________________________________________________________
Past:______________________________________________________________________________________________________________________________________ 

Vaccinations:                      Date                          Reactions
________________________________________________________________________________________________________________________________________________
Health Concerns:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________