Child Questionnaire

(Please answer questions on a separate sheet of paper)
Child's Name:
Parents:
Address:
Phone:
E-mail:
Date of Birth:                                     Birthweight:

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
     blood.
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?
     weaning        closing of fontanels        first milk teeth
     talking           toilet training                 first permanent teeth
     crawling         walking
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.
      vaccinations
      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 at school?
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.)
      or behaviourally?
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 or feet?
21. Is your child exceptionally affectionate?
22. Is he/she unusually sympathetic, showing concern for the suffering of other children, animals,
      etc.?
23. Does your child like music? What kind? Dancing? Do some symptoms (like restlessness)
      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 him/her?
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, deaths,
      etc. Describe how your child reacted to these events?
29. Are there diseases that tend to run in your extended family? If so, please specify.


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