(Please answer questions
on a separate sheet of paper)
Date of Birth:
1. What is your child's chief complaint (CC)?
2. When did this problem begin? What do you think caused it?
3. What aggravates the CC (certain types of food or weather,
noise, heat/cold, bright light, or
anything else that you can think of?
4. At what time of the day or night is the CC the worst?
5. What symptoms can you identify that accompany the CC?
6. During the pregnancy, did you suffer any particular
shocks, traumas, losses (physical or
emotional)? For example, a loss could
be the death of a loved one or depletion from loss of
7. Did you take any drugs/medications during pregnancy?
8. Were there complications at birth?
9. At what age did your child achieve these stages?
closing of fontanels
first permanent teeth
10. How did your child react to these situations? Please try to think
of mental and emotional
reactions as well as any physical
symptoms that may have developed.
birth of a younger sibling
starting daycare or school
spending the night at a friends house
or going away to camp, etc., without the family
11. How many rounds of antibiotics has your child had, and for what?
12. Any skin conditions treated with cortisone cream?
13. Did your child suffer from a childhood disease with very severe
symptoms? How treated?
Did the state of your child's health
or behaviour change after
the disease resolved?
14. When ill or upset, does your child tend to cling to you or want to
be left alone?
15. How does your child behave when playing with other children?
16. What feedback do you get from your child's teacher about behaviour
17. What is your child's attitude towards pets, animals?
18. What foods does your child crave?
What type of foods will he/she not eat?
What type of food does your child
react badly to, whether physically (bloating, diarrhea, etc.)
19. Does your child have any unusual fears (of the dark, being alone,
thunderstorms, etc.)? Are
there night terrors or nightmares?
20. Is your child chilly? Is there excessive perspiration on the head
21. Is your child exceptionally affectionate?
22. Is he/she unusually sympathetic, showing concern for the suffering
of other children, animals,
23. Does your child like music? What kind? Dancing? Do some symptoms
improve with music and/or dance?
24. Is your child obstinate? How does he/she express this?
25. Is your child fastidious?
26. Is your child sensitive to being disciplined, reprimanded? What is
his/her response if another
child or acquaintance criticizes
27. Can you think of any unusual or distinctive things about your child
-- aversions to certain
colors, fantasies, attachments,
preference in toys/clothing, etc.?
28. Construct a timeline
for your child that includes traumas, diseases, important events,
etc. Describe how your child reacted
to these events?
29. Are there diseases that tend to run in your extended family? If so,