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Children Questionnaire
Children Questionnaire
Child Full Name
Gender
Male
Female
Date Of Birth
Age
Chief Complaint (Medical Condition)
Name Of Parent
Gender
Male
Female
Skype Name
Email
Area Code
Phone Number
Mobile Number
Date Of Birth
Age
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to child
What does he/she worry about?
Is the child more fastidious or neater than those around?
Does the child cry easily?
Yes
No
In what situations?
When the child is upset, does she/he tend to:
Tend to talk about it
Keep it to herself
On what occasions does the child feel despair?
In what circumstances does the child feel jealous?
In what circumstances does the child feel frightened?Any fears, please specify (e.g. dark, snakes, dogs, rats, etc., heights, ghosts, robbers, claustrophobia, agoraphobia, diseases, water, death, anything that makes him/her feel uneasy):
What where the major grieves that the child suffered in his/her life?
How did the child react?
What were the greatest joys the child had in his/her life?
In what situations does the child feel sad, depressed, pessimistic?
How does the child express it?
What would the child need to feel happy?
Does the child have lack of confidence and poor sense of self worth?
Lack of self confidence
Poor sense of self worth
Ideally what would he/she like to do for a living when she grows up?
How does other people view him/her (e.g. friends, teachers, other members of the family)?Please give a short description of the child’s character.
What are the child favorite hobbies?
If possible, mention vaccinations received:
Any adverse reactions?
Describe Childhood diseases that happened so far and if it happened twice or in a very severe form:
What medications is the child taking at the present?
How was the pregnancy?
Any worries or major events?
Did you have food cravings or strong aversions during the pregnancy?
How was the birth?
Birth weight:
At what time did the child start:
Teething
Crawling
Walking
Talking
Toilet training (night)
Hi Toilet training (day)
What was the child’s reaction on the 1st day at school?
And spending a night without the family?
Any skin conditions treated with cortisone cream?
How does the child behave when playing with other children?
Does it make a difference if they are older or younger?
What feedback do you get from the teacher about the child behavior in class?
What’s the child attitude towards pets?
When the child is ill does he tend to cling to you or wants to be left alone?
Is the child very affectionate when not sick?
Does the child like Music?
Yes
No
What kind?
Does the child like dancing
Yes
No
Is the child obstinate?
Yes
No
Sometimes
It Varies
How does the child express it?
Is the child sensitive to criticism when reprimanded?
Can you think about any thing distinctive or unusual on the child behaviour like fears, desires attachments, preferences etc.?
Any surgeries? (please give details if any)
Does the child have or has had any of the following?
Polyps
Yes
No
Cysts
Yes
No
Warts
Yes
No
Tumours
Yes
No
Moles
Yes
No
9Figworts
Yes
No
Does the child tend to have any discharges:
Nasal
Urethral
From the Ears
Type option 4
Other
Other
Please describe colour and consistency
Does it have any particular smell?
Does the child react bad to anesthesia or had a hard time to come out of it (e.g. headaches, vertigo, nausea, vomiting)?
Does the child tend to react badly to medication
Yes
No
_Is the child sensitive to paint, perfumes, exhaust, fragrances, etc?
Yes
No
Fears
In what circumstances does the child feel frightened?Any fears, please specify (e.g. dark, snakes, dogs, rats, etc., heights, ghosts, robbers, claustrophobia, agoraphobia, diseases, water, death, anything that makes him/her feel uneasy):
Temperatures
Which season bothers the child the most?
Autumn
Winter
Spring
Summer
How do the child feel in bright sun light?
How do the child feels in drafts?
Any reactions before or after a storm?
How does the child feel at seashore or high in the mountains, please specify preference?
How does the child feel before and after meals?
What if the child escapes a meal?
What is the child favorite food (please disregard any idea of what is healthy or not, I need to know what she truly likes, even if it is the fat of the bacon!)?
What food does she/he dislikes and refuses to eat?
Foods that the child may like but reacts badly: And in what way?
How much does the child drink in a day?
Comparing with other children, does the child tend to get more or less thirsty?
More
Less
It depends
How many hours does the child sleep in average (please include time to go to bed and waking up time)?
Does the child tend to wake up in the middle of the night? And at what time?
Does the child do anything during sleep (laugh, speak, snoring, grinding the teeth, toss about)?
How does the child feel in the morning immediately after waking? Cranky or happy going?
In which position does the baby tend to sleep (sides, back or abdomen)?
Side
Back
Abdomen
Does the child have recurrent dreams?
Is there a main theme?
Does the child perspire a lot?
Yes
No
When and where in the body?
Look for any involuntary movements.
Involuntary darting of the tongue in and out.
Nystagmus (involuntary, rapid oscillation of the eye balls.
Rhythmic oscillation of the eyeballs, either horizontal, rotary or vertical).
What Position does he/she dislike the most, lying, standing, sitting: lying down
Skin (eruptions, itchiness):
Bowels regularity:
What Time of the Day does the child tend to be a down and more cranky?
Is there anything else you would like to tell me?
Mother
Father
Siblings
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Please try to construct a time line with major grieves/traumas that happened in your life (events that marked you or had an impact in your life in chronological order, example below)
2 month old - Dropped on the floor during nappy change
6 month old - Moving from a flat to a bigger house
1 year old - Death of grandparent that affected the mother greatly
1-2 years old - Screaming fights between parents
Send
