MEDICAL – EDUCATIONAL HISTORY FOR HOLISTIC MANAGEMENT OF CHILDRENs (DIRECTION FOR A WRITTEN SUBMISSION)

	INTRODUCTION:
	1.  For holistic management of your child, it is important for us to understand the family set up, child’s behaviour, temperament, pattern of relationship and scholastic performance. Accordingly we have designed this questionnaire. The information you supply forms the basis of further investigation. Full co-operation therefore, is required- ALL INFORMATION SUPPLIED IS, OF COURSE STRICTLY CONFIDENTIAL. 2. Also for finding out a correct Homoeopathic Remedy, lot of information with regard to the (I) Complaints- (a) main as well as (b) subsidiary- and (II) The person of the patient is required. 3. Incomplete information will make correct choice difficult. You are therefore requested     to supply all information without keeping back anything as irrelevant or of little importance. 4. Since the inquiry can be a time consuming process and lot of information is being collected     we require to record it systematically and, at times, we might call for second interview.     To facilitate this, we have evolved a special procedure in which the preliminary study     is carried out by a physician specially assigned to this job and when your Case Record     is ready, we examine it for instituting treatment. 5. Children with Psycho-educational problems will be investigated in details by various experts.     Suitable appointments will be given to them. 6. We are sure you shall be fully co-operating with us in rendering you the best     possible Service.
	PRELIMINARY INFORMATION:
	Please supply the following information as standard routine: Name in full, Address, Date- of-Birth, Sex, Religion/Community/sect, School, Standard, Vegetarian / Non-Vegetarian/ Eggs, Habits: Tea, Coffee, Milk, Chocolates, etc. Description of the current family set up, full description pertaining to all the members, their ages, location, work they are doing, their monthly income and the child’s relationship with them. Include in your list those who have died stating the age of death, the year and cause for the same. State if the parents have married within family (i.e. Consanguineous marriage). Child’s daily routine from getting up in the morning to retiring at night. Include in this dietary schedule furnishing full details in respect of the quantities consumed. State the time spent for studies and recreation.
	HISTORY OF PRESENT PROBLEMS:
	For children having psychological & educational problems:
	Give your understanding of child’s psychological, educational & medical problems: focusing on:
	1.   How and when it started, any significant event associated with it. 2.   Description of the complaint: Frequency / Duration / Presentation of the complaint. 3.   Nature of the previous treatment taken if any and its effect.
	Other Complaints:
	Full description of the trouble right from the time of onset. It’s subsequent development, spread and response to treatments taken. This should give full idea of:
	1.       Area affected: Location, extension, direction of spread, the march of events. 2.       Sensation experienced in the area of trouble. 3.       Condition that have brought on the trouble: examine the circumstances that            obtained, Just before or at time of onset paying attention to physical as well as                emotional factors. 4.       Condition that increase the trouble or those that afford relief. 5.       Other troubles experienced at the same time along with the main trouble for               example…perspiration/ nausea/ vomiting/ gas/ with pains.
	PERSONAL HISTORY:
	1.   Data pertaining to another mother: (a) Health during pregnancy                              i) Physical complaints during pregnancy ii) Emotional state during pregnancy (b) History of miscarriages/ abortions before or after (c) Any treatment taken to conceive (d) Term of pregnancy: Full term/pre mature/post mature. (e) Type of delivery (f ) Give details pertaining to the child under following head: (i)  Birth weight (ii) Any known problems after delivery (attach hospital Card for the information). (iii) Any congenital defects. (iv) Physical Disability: temporary / permanent (v)  Early development: State the age at which child started Sitting, Teething,       Crawling, Talking, Standing, Bladder control, Walking, Bowel control.
	Give a full account of the following:
	1. Physical description of the child. 2. (a) Emotional nature: anger, fears, attachments, shyness etc. Mention if you have noted          any change in child’s Behaviour / Nature recently. (b) Intellectual attainments: School performance, Extracurricular activities, Hobbies, etc. (c) Give a clear cut Picture of child’s relationship with the family members, friends and teachers school/ tuition. Discuss the difficulties experienced by the family if any present as well as past). (d) describe child’s behaviors: (i)In group of Children (ii) With guests (iii) While attending party or function? 3. Reactions to surroundings. (a)Food: desire and aversions including desire for chalk, earth, etc. foods that do not suit, etc. (b) General environment: Weather, Temperature, Bath, Cloths, Covering etc. (c) Sleep and dreams.
	SCHOOL HISTORY: (For children with psychological & educational problems):
	(i)Name and Address of School attending at present. (ii) Class in at Present. (iii)School timing. (iv) Medium of instruction. (v) Age of starting school. (vi) Names and dates of school attended in the past and reasons for changing. (vii)Any change in medium of instruction. (viii)Early school experience. (ix)Regularity in school. (x)Adjustment in school: with teachers : with peers. (xi)Interest in studies. (xii)Academic performance. (xiii)Any change in performance in the school. (xiv)Any discontinuation of failure in studies (specify the period, class and possible reasons). (xv)Any specific learning disability. (xvi)Participation in school activities. (xvii)Participation in extra-curricular activities. (xviii)Does the child get help in his/her studies at home? (xix)His relationship with the person who helps the child with school work.
		PREVIOUS ILLNESS:
		Give a resume of the various illnesses the child has had and to what extent those have any bearing on present troubles.
		FAMILY HISTORY:
		Data concerning the Parents, Brothers and Sisters. Also state details concerning the health of grand paents and other blood relative on both sides.
		GENERAL COMMENTS:
		Include here any items, which have not been included above.
		ENCLOSURE:
		1. Referral note from your Physician (if you have been referred) & Old Medical Records. 2. Please attach the Xerox copies of previous school reports, teacher’s notes, medical     reports, and psychological evaluation if any. 3. X-ray, Sonography, CT Scan etc., if any
		M.B.Barvalia Foundation’s HOLISTIC CHILD CARE CENTER & SPECIAL SCHOOL Opp. Jain Temple, Opp. Bldg. No. – 161, Naidu colony, Pant Nagar, Ghatkopar (E),  Mumbai - 400075. India. Phone:- 91-22-25134467. Mail ID : spandan@holisticfoundation.org