Pediatric Homeopathic General Form

Transcription

1 Name: The following general symptoms pertain to you as a whole person. Date: Which are you generally most sensitive to, warm or cold? Which weather conditions are you most troubled by? Cold Warm Cloudy Clear What times of day are you generally worst (mood, energy, symptoms, etc.) What times are you best? Wet Dry Worst Best Damp cold Snow (Dry cold) Storms Wind Fog Hot Sun AM AM Circle which seasons cause you the most trouble? PM PM Winter Fall Spring Summer Are you affected being in the: Mountains Seashore Are you generally sensitive to and/or troubled by: Bright Light Darkness Open Air Stuffy Rooms Tight Clothing Noise Odors Drafts Are you generally chilly or warm? Symptoms during sleep. Circle which you have. Tooth Grinding Restlessness Talking Perspiration Frequent Urination Excess Heat or Cold Laughing Snoring Nightmares Recurring Dreams Sleepwalking Circle what you prefer. Do you sleep: Without Covers Partly Covered Fully Covered (Not including Head) Fully Covered (Including Head) With Arms or Legs Out of the Covers Without Clothing With a Fan or Air Blowing on You With the Window open What position do you sleep in most often? Right Side Left Side On Back On Abdomen Chilly Warm 1126 Sam Newell Rd., Suite A Matthews, NC Ph: Fax:

2 How much do you perspire? Pediatric Homeopathic General Form Coffee Pastries Do you have difficulty waking? Food Desires and Aversions: In the following questions you are asked how much you desire or are averse to a particular food or taste. Please answer from the point of view of your natural desires, not your knowledge of nutrition. If you strongly desire or crave a food or taste, mark 10. If you detest a food or taste, mark 1. Tastes: Sweet Sour Salty Bitter Spicy (hot) Smoked Juicy Refreshing Pungent Foods: Alcohol Apples Bacon Eggs Fat (meat) Fish Fruit Fruit (sour) Grain foods Ham Ice Ice cream Indigestible things Lemonade Meat Milk Nut butters Oysters Pickles Vegetables Vinegar Temperature of food. Which do you prefer? Warm Food Cold Food Bread alone Bread w/ butter Butter alone Cheese Chocolate Warm Drinks Cold Drinks 1126 Sam Newell Rd., Suite A Matthews, NC Ph: Fax:

3 Do you notice any specific tastes in your mouth (e.g., metallic, bitter, foul, etc.)? Answer as honestly as you can about your personality traits. How thirsty are you generally? Stingy Overly generous Not at all Very Mental and Emotional State: How strong in general are the following emotional symptoms? The most mark 10. The least mark 1. Anxiety (worry and fear) Do you worry about any of the following? 10 means the most, 1 the least. Creative Activities Emotions Financial Security Health Mental Function Morals Others well being Religion Social Life Social Position Hurried, impatient Slow Messy Calm Fastidious Restlessness Indolence (Lazy) Always busy Shyness/Timid/Bashful Outgoing Anger Mildness Lack of moral sense Guilty Obstinate (stubborn) Yielding Heedless/Reckless Cowardice Social/Antisocial. In regard to being with other people or in company? Aversion Desire for The Future Work Irresolution (not being able to decide or stick to a decision Capriciousness (Willfulness, changeable & erratic desires that are difficult to satisfy) Selfishness Frightened Easily Afraid 1126 Sam Newell Rd., Suite A Matthews, NC Ph: Fax:

4 Circle the expression that best describes your feelings about the following issues. Significant past emotionally traumatic events: Resolved Grief Dwells on Past Inconsolable Remorse Guilt Feeling towards people close to you: Loving Affectionate Indifferent Resentment Hatred Other Feeling toward disease/condition: Feeling toward life Optimistic Doubtful of recovery Discouraged Fearful Despair of recovery Other Love life Indifferent Bored Weary of life Loathing of life Desires death Suicidal thoughts Suicidal disposition Other How much do you have the following symptoms? 10 a lot, 1 hardly ever. Irritability Jealousy Alternating Moods Even Moods Circle which best expresses your general mood. Morose Sad Apathy/Indifferent Excitement Exhilaration Other How do you experience sympathy or consolation? Like Dislike Better from Worse from How talkative are you in general? Aversion to talking Talkative Not trusting Trusting Gullible Suspicious How often and easily do you weep? Often How often do you experience clairvoyance (predict future events)? Often How is your level of self-confidence? Lack of confidence Pride/Haughty How impulsive are you? Often 1126 Sam Newell Rd., Suite A Matthews, NC Ph: Fax:

5 How afraid are you of the following? (1, never. 10, very afraid) It is common for children to have fears, but if the fear is stronger than normal please indicate. Animals Being alone Death Relative s Death Impending Disease Downward Motion Evil Falling Ghosts Heights Insanity Misfortune (bad luck) Of a Crowd People Robbers Snakes Spiders Strangers Something bad will happen Are you forgetful of any of the following? (1 not at all, 10 a lot) Dates Names Numbers Of what someone just Said Of what you just said Of words How often do you make mistakes with the following? Numbers Reading Speaking Writing How sensitive are you to any of the following? Beauty Criticism Cruel Stories Frightening things Being made fun of Music Reprimand Rudeness The suffering of others Darkness Thunderstorms Water Wind 1126 Sam Newell Rd., Suite A Matthews, NC Ph: Fax:

6 How do you usually handle conflict? Quarrelsome Yielding How are you in regard to authority? Bossy/Dictatorial Yielding/Fawning How critical are you of others? Not at All How critical are you of yourself? Not at All How honest are you? Always Lie Always honest How often do you have the following behaviors? Abusive Biting Breaks Things Contrary-opposite to what is logically expected Cursing Disobedience Insolent (insult, boldly rude) Rage Rudeness Striking others Striking self Violence 1126 Sam Newell Rd., Suite A Matthews, NC Ph: Fax: