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Please complete, sign, and submit this online form at least 48 hours prior to your child’s scheduled Initial Intake Appointment.

Homeopathic Treatment Health Inventory Form (Child)

Evoke Homeopathy & Wellness
General Information
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Address (Parent/Guardian) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail (Parent/Guardian) *
Phone Number (Parent/Guardian) *

Area Code Phone Number
Child's Gender Identification
How did you hear about Evoke Homeopathy & Wellness?
Medications
It is strongly recommended that your child remain under the care of a physician. If your child is taking prescribed medications, he/she will need these to be monitored during and after homeopathic treatment, since the need for them may change as your child's health improves. *

I acknowledge (parent/guardian)
What medications, supplements and over the counter items does your child take regularly or is currently prescribed: *
Has your child had any surgeries or hospitalizations? If so, please list. *
Has your child ever been prescribed steroid medications (albuterol, nebulizer treatments, topical steroid creams, etc. .) for skin issues, asthma, or anything else?
If so, please list the reason(s) and date(s) of steroid prescription(s).
How did your child respond to the steroid prescription?
Sleep And Mood
What are your child's interests/hobbies/extracurricular activities?
Does your child enjoy school?
Does your child get regular exercise?
Does your child have difficulty falling or staying asleep?
How many hours does your child sleep?
How would you describe your child's energy level?
Does your child have any fears? If so, please list.
How would you describe your child's mood, generally?

Check items that apply to your child either currently or in the past *

No, never

Yes, currently

Not currently, but within the last year

Not currently and longer than 1 year ago

Allergy/Asthma

Anemia

Anorexia

Arthritis (Juvenile)

Binge Eating/Bulimia

Cancer

Diabetes

Epilepsy or Seizures

Heart Disease

Skin Disease

Kidney Disease

Liver Disease

Mental Illness

Obesity

Suicide

Thyroid Disease

Tuberculosis

Ulcer

Anxiety

Developmental Milestones
Is your child meeting their developmental milestones?

Yes No
If not, please explain.
How is your child's appetite?
How many meals per day does your child eat?
Please list any food allergies or intolerances.
Health History

Check items that apply to blood relatives/family health history. *

Mother

Father

Maternal Grandparent

Paternal Grandparent

Sibling

Other

N/A

Alcohol/Drug problem

Allergy/Asthma

Anemia

Anorexia

Arthritis

Binge Eating/Bulimia

Cancer

Diabetes

Epilepsy or Seizures

Heart Disease

Skin Disease

Gonorrhea

High Blood Pressure

High Cholesterol

Kidney Disease

Liver Disease

Mental Illness

Obesity

Stroke

Suicide

Thyroid Disease

Tuberculosis

Ulcer

Reasons For Seeking Homeopathic Treatment
Why are you seeking homeopathic treatment for your child?
Has your child had homeopathic treatment for these issues in the past?
If so, how was your child's experience?
Please list all homeopathic remedies your child has taken that stand out in your memory either for their positive or negative effects.
Just one last box to write anything important that you'd like me to know before we begin treatment...
Signature (Parent/Guardian)

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Please complete, sign, and submit this online form at least 48 hours prior to your child’s scheduled Initial Intake Appointment.

Homeopathic Treatment Health Inventory Form (Child)

General Information

Medications

Sleep And Mood

Developmental Milestones

Health History

Reasons For Seeking Homeopathic Treatment