Naiminath

Condition for which you are seeking homeopathic treatment (please list all issues you would like to address, we will address these and more during your appointment):

Fetal / Birth/ Young Life Information

Please state (if known) the health of your mother when she was pregnant with you: Did your mother suffer from

Please describe any other issues that arose with your mother’s pregnancy:

C-Sections

Regarding your birth:

Average Caesarean Long/ difficult Delayed Breech Forceps used Premature

What was the weight of the infant at the time of birth?

At which ages did you develop:

Teeth

Ability to crawl

Ability to walk

Ability to talk

If you are unsure, do you know if these events occurred within the standard age frames?

Illness History

If you have been affected by any of the following, please indicate approximately what age you were, and if it was severe orlong-lasting.

Chicken pox

Mumps

German measles

Pneumonia

Measles

Scarlet fever

Mononucleosis

Whooping cough

Typhoid

Accident/Injury

Dengue

Animal Bite

Malaria

Surgical History

Other illnesses

Have you suffered from recurring:

Vaccinations

Have you had reactions to any vaccinations? Yes No

Did your health decline after a vaccination? Yes No

Have you had allergy desensitization injections? Yes No

Check all boxes that describe the symptoms/ pain:

What makes the pain/ symptom better (ex. Heat, cold, motion, being still, menstrual cycle, full moon, sitting, lying, going up steps, running, motion, walking, emotions, etc. )

Is there a specific time of day that your symptoms are worse?

Do you have pain/ symptoms on a daily basis? Yes No

Does the pain extend to another location? If so, where?

Family Health History

Indicate in the following chart which ailments have affected your relatives- including their ages- to the best of your ability.

Possible ailments include, but are not limited to: AIDS/HIV, alcoholism, allergies (food, environmental, medications), arthritis/rheumatism, asthma, cancer, diabetes, epilepsy, frequent colds, gonorrhea, gout, hay fever, heart problems (high blood pressure, angina, strokes, etc.), Hepatitis A/B/C, hernia, herpes (oral, genital), hysteria, jaundice, lung disease, mental illness (including suicides), obesity, paralysis, pleurisy, pneumonia, skin problems (eczema, psoriasis), thyroid problems, tuberculosis, ulcers, warts (skin, genital), other venereal diseases (syphilis, gonorrhea, chlamydia, etc), and any other issues you know of.

*Please indicate if you have also had any of these conditions, even if they have been treated/ resolved.

Relation

Age if alive

Age at passing

Ailments

Mother

Father

Siblings

Maternal Grandmother

Maternal Grandfather

Maternal Aunts/ Uncles

Paternal Grandmother

Paternal Grandfather

Paternal Aunts/ Uncles

Significant Life Events:

Traumatic events can impact your health. Discussing them can often be difficult. It is not necessary for us to discuss the details of these events. However, it is very helpful to know what the effects of the events were, how they left you feeling after the event, etc. If you would rather, we can review this in person.

If you are able, please complete a timeline from birth to present. Situations such as: traumas of your mother during pregnancy with you, romantic disappointments, divorces, work issues, family issues, death of loved ones, humiliations/embarrassments, and other events that have impacted you. Please include on this timeline dates of major illness and onset of physical or emotional issues, including conditions that were treated with suppressive medications.

Include positive events such as marriages and birth of children. Use a separate sheet, other side of a page, or the end of this form.

Childhood

Nature

a. Reaction during anger; If expressed explain how

Throwing things Shouting Sitting alone Avoiding food Abusing/Fighting

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Fetal / Birth/ Young Life Information

C-Sections

Regarding your birth:

At which ages did you develop:

Illness History

Have you suffered from recurring:

Vaccinations

Check all boxes that describe the symptoms/ pain:

Family Health History

Significant Life Events:

Childhood

Nature

a. Reaction during anger; If expressed explain how