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Kavitha Holistic Approach Kavitha Kukunoor CCH, RSHom(NA), BHMS Homeopathic Consultant State (India) License: Regd. No 348 SAIHO M EO P A TH IC C O N SU LTIN G K avitha K ukunoorB H M S,CCH,RS Hom (N A),FR H S State (India)License:R egd.N o 348 C ertified C lassicalH om eopath O urrefno: D ate: AG REEM ENT FO R HO M EO PATHIC TREATM ENT FO RM (BLO CK LETTERS PLEASE) FIR ST N AM E:________________________________________ LAST NAM E :__________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________PO STCO D E_________ ___ TELEPHO N E (H O M E)________________ M O BILE:_________________ (W ORK)________________E-M AIL:_____________________ DATE O F BIRTH /AG E:________________ _/________ O C C U PATIO N :________________________________________________: BIR TH PLAC E:________________________________________________ M AR ITAL STATU S:(C IR C LE O NE) SIN G LE /M AR R IED /LIVIN G PARTNER /SEPARATED /DIVO RCED / Kavitha Kukunoor Classical Homeopath Email:[email protected] 1

Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

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Page 1: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Kavitha Holistic Approach

Kavitha Kukunoor CCH RSHom(NA) BHMSHomeopathic ConsultantState (India) License Regd No 348Phone 248 ndash 974 ndash 6046 Email Infokavithakhomeocom

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom1

Website wwwkavithakhomeocom

HOMEOPATHIC CLIENT (CHID) CASE - RECORD

Name_________________________ Age_________ Birthdate ________ Sex ____

Address________________________ City______________ State_____ Zip_______

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom2

Phone (home) _______________ (work) ______________ Email _________________

Occupation ______________________

Marital status ____________________

How did you hear about this office_________________________

Name of family doctor or clinic____________________________

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom3

If the patient is a child please indicate the following

Motherrsquos Name___________________ Child lives with you_______

Fatherrsquos Name____________________ Child lives with you_______

What vaccinations has the child taken______________________

YOUR HEALTH HISTORY

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom4

What medications do you currently take_______________________________________

What medications have you taken in the past___________________________________

Have you had any of the previous illnesses (Please indicate the diagnosis and when it occurred)Autoimmune diseaseCancerHeart Disease

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom5

High blood pressureDiabetesMental illnessNeurological disordersPneumoniaTuberculosisVenereal diseases

Any surgeries or hospitalizations

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom6

Important Message

A Homeopathic remedy is mainly selected based on the symptoms you (client patient) give us If we are to make a successful Homeopathic remedy selection we must know all the details of your sickness We must also understand all the features that belong to you as an individual This includes your reactions to various factors your past and family history and your mental condition All this information enables us for proper selection of the remedy that removes your sickness The Homeopathic medicine also makes you well as a whole person

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom7

In order to find out all about you we shall be asking you many questions Each one of these questions has a definite meaning and significance for us There is not a single question that is useless Even something that your may think is not connected with your trouble may be the most important factor in deciding the correct homoeopathic medicine That is why you must be free and frank and give us the fullest possible information on each point Please read each question carefully think and then answer completely Do not keep anything back Remember whatever you tell us will remain absolutely confidential

We may ask you the same questions again and again This does not mean that your answers are not clear or that we did not understand them We found that by asking some questions repeatedly

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom8

we are able to get a clearer perception of what your inner experience is and this is vital to find a good remedy for you

THIS QUESTIONNAIRE FORM HAS BELOW MENTIONED SECTIONS

About your past illnesses and family illnesses Please take time to answer this part with the help of your family members

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom9

History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom10

About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom11

HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom12

migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom13

A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom14

the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom15

SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom16

DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom17

The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom18

Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom19

Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom20

EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom21

MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom22

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom23

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom24

Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom25

OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom26

Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 2: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Website wwwkavithakhomeocom

HOMEOPATHIC CLIENT (CHID) CASE - RECORD

Name_________________________ Age_________ Birthdate ________ Sex ____

Address________________________ City______________ State_____ Zip_______

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Phone (home) _______________ (work) ______________ Email _________________

Occupation ______________________

Marital status ____________________

How did you hear about this office_________________________

Name of family doctor or clinic____________________________

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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If the patient is a child please indicate the following

Motherrsquos Name___________________ Child lives with you_______

Fatherrsquos Name____________________ Child lives with you_______

What vaccinations has the child taken______________________

YOUR HEALTH HISTORY

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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What medications do you currently take_______________________________________

What medications have you taken in the past___________________________________

Have you had any of the previous illnesses (Please indicate the diagnosis and when it occurred)Autoimmune diseaseCancerHeart Disease

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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High blood pressureDiabetesMental illnessNeurological disordersPneumoniaTuberculosisVenereal diseases

Any surgeries or hospitalizations

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Important Message

A Homeopathic remedy is mainly selected based on the symptoms you (client patient) give us If we are to make a successful Homeopathic remedy selection we must know all the details of your sickness We must also understand all the features that belong to you as an individual This includes your reactions to various factors your past and family history and your mental condition All this information enables us for proper selection of the remedy that removes your sickness The Homeopathic medicine also makes you well as a whole person

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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In order to find out all about you we shall be asking you many questions Each one of these questions has a definite meaning and significance for us There is not a single question that is useless Even something that your may think is not connected with your trouble may be the most important factor in deciding the correct homoeopathic medicine That is why you must be free and frank and give us the fullest possible information on each point Please read each question carefully think and then answer completely Do not keep anything back Remember whatever you tell us will remain absolutely confidential

We may ask you the same questions again and again This does not mean that your answers are not clear or that we did not understand them We found that by asking some questions repeatedly

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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we are able to get a clearer perception of what your inner experience is and this is vital to find a good remedy for you

THIS QUESTIONNAIRE FORM HAS BELOW MENTIONED SECTIONS

About your past illnesses and family illnesses Please take time to answer this part with the help of your family members

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom22

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom23

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom24

Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom33

Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 3: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Phone (home) _______________ (work) ______________ Email _________________

Occupation ______________________

Marital status ____________________

How did you hear about this office_________________________

Name of family doctor or clinic____________________________

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom3

If the patient is a child please indicate the following

Motherrsquos Name___________________ Child lives with you_______

Fatherrsquos Name____________________ Child lives with you_______

What vaccinations has the child taken______________________

YOUR HEALTH HISTORY

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom4

What medications do you currently take_______________________________________

What medications have you taken in the past___________________________________

Have you had any of the previous illnesses (Please indicate the diagnosis and when it occurred)Autoimmune diseaseCancerHeart Disease

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom5

High blood pressureDiabetesMental illnessNeurological disordersPneumoniaTuberculosisVenereal diseases

Any surgeries or hospitalizations

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom6

Important Message

A Homeopathic remedy is mainly selected based on the symptoms you (client patient) give us If we are to make a successful Homeopathic remedy selection we must know all the details of your sickness We must also understand all the features that belong to you as an individual This includes your reactions to various factors your past and family history and your mental condition All this information enables us for proper selection of the remedy that removes your sickness The Homeopathic medicine also makes you well as a whole person

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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In order to find out all about you we shall be asking you many questions Each one of these questions has a definite meaning and significance for us There is not a single question that is useless Even something that your may think is not connected with your trouble may be the most important factor in deciding the correct homoeopathic medicine That is why you must be free and frank and give us the fullest possible information on each point Please read each question carefully think and then answer completely Do not keep anything back Remember whatever you tell us will remain absolutely confidential

We may ask you the same questions again and again This does not mean that your answers are not clear or that we did not understand them We found that by asking some questions repeatedly

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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we are able to get a clearer perception of what your inner experience is and this is vital to find a good remedy for you

THIS QUESTIONNAIRE FORM HAS BELOW MENTIONED SECTIONS

About your past illnesses and family illnesses Please take time to answer this part with the help of your family members

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

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Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

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(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 4: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

If the patient is a child please indicate the following

Motherrsquos Name___________________ Child lives with you_______

Fatherrsquos Name____________________ Child lives with you_______

What vaccinations has the child taken______________________

YOUR HEALTH HISTORY

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom4

What medications do you currently take_______________________________________

What medications have you taken in the past___________________________________

Have you had any of the previous illnesses (Please indicate the diagnosis and when it occurred)Autoimmune diseaseCancerHeart Disease

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom5

High blood pressureDiabetesMental illnessNeurological disordersPneumoniaTuberculosisVenereal diseases

Any surgeries or hospitalizations

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom6

Important Message

A Homeopathic remedy is mainly selected based on the symptoms you (client patient) give us If we are to make a successful Homeopathic remedy selection we must know all the details of your sickness We must also understand all the features that belong to you as an individual This includes your reactions to various factors your past and family history and your mental condition All this information enables us for proper selection of the remedy that removes your sickness The Homeopathic medicine also makes you well as a whole person

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom7

In order to find out all about you we shall be asking you many questions Each one of these questions has a definite meaning and significance for us There is not a single question that is useless Even something that your may think is not connected with your trouble may be the most important factor in deciding the correct homoeopathic medicine That is why you must be free and frank and give us the fullest possible information on each point Please read each question carefully think and then answer completely Do not keep anything back Remember whatever you tell us will remain absolutely confidential

We may ask you the same questions again and again This does not mean that your answers are not clear or that we did not understand them We found that by asking some questions repeatedly

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom8

we are able to get a clearer perception of what your inner experience is and this is vital to find a good remedy for you

THIS QUESTIONNAIRE FORM HAS BELOW MENTIONED SECTIONS

About your past illnesses and family illnesses Please take time to answer this part with the help of your family members

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom9

History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom10

About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom11

HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 5: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

What medications do you currently take_______________________________________

What medications have you taken in the past___________________________________

Have you had any of the previous illnesses (Please indicate the diagnosis and when it occurred)Autoimmune diseaseCancerHeart Disease

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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High blood pressureDiabetesMental illnessNeurological disordersPneumoniaTuberculosisVenereal diseases

Any surgeries or hospitalizations

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Important Message

A Homeopathic remedy is mainly selected based on the symptoms you (client patient) give us If we are to make a successful Homeopathic remedy selection we must know all the details of your sickness We must also understand all the features that belong to you as an individual This includes your reactions to various factors your past and family history and your mental condition All this information enables us for proper selection of the remedy that removes your sickness The Homeopathic medicine also makes you well as a whole person

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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In order to find out all about you we shall be asking you many questions Each one of these questions has a definite meaning and significance for us There is not a single question that is useless Even something that your may think is not connected with your trouble may be the most important factor in deciding the correct homoeopathic medicine That is why you must be free and frank and give us the fullest possible information on each point Please read each question carefully think and then answer completely Do not keep anything back Remember whatever you tell us will remain absolutely confidential

We may ask you the same questions again and again This does not mean that your answers are not clear or that we did not understand them We found that by asking some questions repeatedly

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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we are able to get a clearer perception of what your inner experience is and this is vital to find a good remedy for you

THIS QUESTIONNAIRE FORM HAS BELOW MENTIONED SECTIONS

About your past illnesses and family illnesses Please take time to answer this part with the help of your family members

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 6: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

High blood pressureDiabetesMental illnessNeurological disordersPneumoniaTuberculosisVenereal diseases

Any surgeries or hospitalizations

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Important Message

A Homeopathic remedy is mainly selected based on the symptoms you (client patient) give us If we are to make a successful Homeopathic remedy selection we must know all the details of your sickness We must also understand all the features that belong to you as an individual This includes your reactions to various factors your past and family history and your mental condition All this information enables us for proper selection of the remedy that removes your sickness The Homeopathic medicine also makes you well as a whole person

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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In order to find out all about you we shall be asking you many questions Each one of these questions has a definite meaning and significance for us There is not a single question that is useless Even something that your may think is not connected with your trouble may be the most important factor in deciding the correct homoeopathic medicine That is why you must be free and frank and give us the fullest possible information on each point Please read each question carefully think and then answer completely Do not keep anything back Remember whatever you tell us will remain absolutely confidential

We may ask you the same questions again and again This does not mean that your answers are not clear or that we did not understand them We found that by asking some questions repeatedly

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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we are able to get a clearer perception of what your inner experience is and this is vital to find a good remedy for you

THIS QUESTIONNAIRE FORM HAS BELOW MENTIONED SECTIONS

About your past illnesses and family illnesses Please take time to answer this part with the help of your family members

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 7: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Important Message

A Homeopathic remedy is mainly selected based on the symptoms you (client patient) give us If we are to make a successful Homeopathic remedy selection we must know all the details of your sickness We must also understand all the features that belong to you as an individual This includes your reactions to various factors your past and family history and your mental condition All this information enables us for proper selection of the remedy that removes your sickness The Homeopathic medicine also makes you well as a whole person

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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In order to find out all about you we shall be asking you many questions Each one of these questions has a definite meaning and significance for us There is not a single question that is useless Even something that your may think is not connected with your trouble may be the most important factor in deciding the correct homoeopathic medicine That is why you must be free and frank and give us the fullest possible information on each point Please read each question carefully think and then answer completely Do not keep anything back Remember whatever you tell us will remain absolutely confidential

We may ask you the same questions again and again This does not mean that your answers are not clear or that we did not understand them We found that by asking some questions repeatedly

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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we are able to get a clearer perception of what your inner experience is and this is vital to find a good remedy for you

THIS QUESTIONNAIRE FORM HAS BELOW MENTIONED SECTIONS

About your past illnesses and family illnesses Please take time to answer this part with the help of your family members

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 8: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

In order to find out all about you we shall be asking you many questions Each one of these questions has a definite meaning and significance for us There is not a single question that is useless Even something that your may think is not connected with your trouble may be the most important factor in deciding the correct homoeopathic medicine That is why you must be free and frank and give us the fullest possible information on each point Please read each question carefully think and then answer completely Do not keep anything back Remember whatever you tell us will remain absolutely confidential

We may ask you the same questions again and again This does not mean that your answers are not clear or that we did not understand them We found that by asking some questions repeatedly

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom8

we are able to get a clearer perception of what your inner experience is and this is vital to find a good remedy for you

THIS QUESTIONNAIRE FORM HAS BELOW MENTIONED SECTIONS

About your past illnesses and family illnesses Please take time to answer this part with the help of your family members

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom12

migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

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(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 9: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

we are able to get a clearer perception of what your inner experience is and this is vital to find a good remedy for you

THIS QUESTIONNAIRE FORM HAS BELOW MENTIONED SECTIONS

About your past illnesses and family illnesses Please take time to answer this part with the help of your family members

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom22

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom23

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 10: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

History of your present illness

About all the parts of your body

Deals with the factors that affect your health Please think carefully about each of the factors mentioned and write what specific effects they have on you

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 11: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

About your mental state and your emotional nature Please write in this part about your situation in life and about all the things that are bothering you Be totally frank and open

About your sleep and dreams

For children (or) you as a child

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 12: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

HOW TO DESCRIBE YOUR COMPLAINTS

Homeopathic system of medicine individualizes the patient and also individualizes the homeopathic medicine It means treat the patient and not just the disease so we try to get all the unique distinguishing features of a patient suffering with a disorder which usually not requested by a medical doctor for diagnosis

Say for example a person who is suffering with migraine from the point of medical doctor he has 3-5 medicines he prescribes to all patients suffering with migraine where as in Homeopathy there are 30-50 medicines which are indicated for migraine so a Homeopath tries to individualize the

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 13: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

migraine patient in order to select most similar or similimum to the patient That means one patient suffering with migraine may feel better by applying pressure to head and other migraine patient gets worse by any kind of pressure so two different medicines needs to be selected for two different patients this is what individualization in homeopathy means What patient seems to be unimportant symptom or sensation is most important from homeopathy standpoint as it is just related to that patient and it is unique

Here we are not using word medical diagnosis nor trying to do medical diagnosis what we are doing is just trying to understand patient suffering from homeopathic stand point

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

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Page 14: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

A homeopathic symptom is qualified by 4 pointso Location (which part is involved)o Sensation (what kind of pain or feeling experienced)o Modalities (what makes worse and what makes better)o Peculiar rare or strange symptom that is not related to the problem (eg

headache relieved by urination)

In homoeopathy selection of remedy is based on precise details of various symptoms from which you suffer To tell or write to a homoeopathic physician I have a headache an eruption a cough would not be enough If you inform him I have headache with sharp shooting pains in

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the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

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(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 15: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

the left side of the head and temple these pains always come on when the slightest cold air strikes the head the pains wailing about or when the head becomes cool then only you have given all the information required for making a good homoeopathic prescription The success of the prescription depends largely on how detailed is your description of the symptoms We require the following details about your symptoms

LOCATION Please give the exact location of sensation pain or eruption Also describe where the pain or sensation spreads

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 16: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

SENSATION Express the type of sensation or the pain that you get in your own words however simple or funny it may seem You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting burning jerking pressing Express the sensation or pain as it feels to you WHAT MAKES YOU WORSE OR BETTER Many factors are likely to influence your trouble Some factors may cause the trouble to increase and some factors may relieve the trouble

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom16

DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 17: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

DISCHARGES You may have a discharge from ulcers fistula eruptions the skin lungs eyes nose ears mouth private parts etc Please describe your discharge under the following aspects

The quantity and the time or condition under which the quantity varies ie when is it better or worse increases or decreases

The consistency Is it thin or thick stringy or clotted

Is it like jelly white of an egg like water sticky forming a scab etc

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom33

Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 18: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

The odour what does it remind you of Does it make the parts sore and in what way

How your general health has been Excellent Good fair Poor

Do you wake up refreshed in the morning Y N

What is your energy level on a scale of 1-10_________(Increasing scale where 0 means no energy)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom18

Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom24

Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom25

OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom26

Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom27

Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom28

Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 19: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Body type (circle what applies) Normal Thin Stocky Overweight Short Average Tall

Height ____ ft_____in Weight_________lb

Have you had any of these tests

Test When Why

Chest X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom26

Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom33

Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Kidney X-ray

GIT

Colon X-ray

Gallbladder X-ray

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 21: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

EKG

Tuberculosis Tests

Other tests

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom24

Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom33

Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 22: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES (AND DETAILED HISTORY OF THE PRESENT ILLNESS THE ONSET AND COURSE WITH DATES)

Complaints Since when Sensation Factors that make you worse or better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom23

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 23: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 24: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

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Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom24

Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 25: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Past illness - Previous diseases

Vaccination History

BCG 10487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom25

OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

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AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 26: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

OPV 104871210487121048712104871210487121048712DPT 10487121048712104871210487121048712Measles 1048712MMR 1048712Booster - I 1048712Booster - II 1048712Hepatitis 10487121048712104871210487121048712

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom26

Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 27: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Any Complaints after vaccinations

Family InformationMajor diseases that your family members are suffering and cause of death

Pregnancy History

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom27

Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom28

Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 28: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Any Laboratory work

Milestones

DentitionDelayed Normal Early (precocity)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom28

Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 29: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Difficult No difficulty

Other MilestoneSittingCrawlingWalking with supportWalking without supportTalking

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom29

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Page 30: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Appetite

bull Good eater Poor eaterbull Eats but emaciatesbull Cant tolerate hunger

Thirst

bull If he sees water ndash will ask to drink does not react

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom30

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

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WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 31: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

bull Ask water on himself mother has to remind to drinkbull School bottle ndash gets emptied remains half remains nil

Cravings

Aversions

Constitution

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom31

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom33

Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 32: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Lean thin ObeseEmaciation of any special parts

Perspiration

SmellProfuse Scanty SeasonalScalp Wets Pillow Face Occiput Mouth Neck Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom32

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom33

Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 33: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Stools

Urine

Sleep position

Dreams

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom33

Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 34: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Thermals

Fan Wants In All Season Seasonal Does Not WantCovering Likes Dislikes Kicks OffParts of body Cold Hot Occiput Palms Foot

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom34

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 35: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Sociability

bull Does the child make eye contact with new faces (guests)---------------

bull Will he go to relatives------

bull Is he comfortable when you go to parties---------

bull New situation new places how he reacts = Comfortable cranky

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom35

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 36: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

bull Any new food (like ice cream) takes refuses initially--------

bull New clothes (stylishgoddy color) wears hesitates initially--------

bull Going to Nursery Playgroupschool Goes nicely cries-------------

bull Going to relatives house agree does not agree

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom36

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 37: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

bull Attention ndash Likes dislikes--------

bull Playing with other children willingly does not play----------

bull Does the child perform in front of outsiders guests--------

Doctorbull Greets when come in ndash Greets does not greet after persuasion------------

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom37

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 38: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

bull Eye contact makes does not make------------

bull Replies to your question yes no------------

bull Examination ndash allows does not allow initial hesitation---------------

Activity

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom38

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 39: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Mental

bull Cranky child Cool child

Physical

bull Runs around house ndash runs not so much

bull Watch TV ndash Sits and watches for long time gets up frequently

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom39

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 40: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Sensitivity

bull If some tags in clothes ndash disturbed no problem

bull If light put on while he is sleeping ndash Wakes Continue sleeping

bull If some noise around while he is sleeping ndash Wakes Continue sleeping

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom40

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 41: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Destructibility

bull If angry ndash Throws things back Weeps

bull Any new toys ndash will remain intact for few hrs or days Remains intact

bull Does he keeps on breaking things yes sometimes never

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom41

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 42: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Reaction to Reprimands

By Parentsbull Hits backbull Weepsbull Does not likebull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom42

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 43: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

bull smiles

Outsiders( friends teachers relatives)

bull Strikes backbull Weepsbull Feels bad but does not expressbull Threatensbull Not affected

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom43

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 44: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

bull smiles

ANGER- What makes him her angry

In Anger how does he react (Reactions)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom44

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 45: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

bull If angry ndash Cries sobsbull If angry ndash Strikes back Weepsbull If angry ndash Weeps Sulksbull If angry ndash Hits himself Hits othersbull Scared Not scared

Study

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom45

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 46: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Studies on his own Force to study

School

Report from teacher

bull Mixes with other children Does notbull Very restless normal

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom46

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 47: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

bull Very talkative not much

Describe the Reaction to

Loud noise

Strangers

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom47

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 48: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Separation from parents

Doctors Hospitals

Animals ndash Dogs etcStorms

Darkness

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom48

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 49: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Music

Stage

Exam

Outdoors( parks theatres etc)

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom49

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 50: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

WEEPING (The child weeps on)

10487121048712Touched10487121048712Reprimanded10487121048712Spoken to10487121048712All day10487121048712Does the child cry easily or not10487121048712Does the child cry loudly or quietly10487121048712When crying does he have to be consoled or he becomes ok on his own

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom50

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 51: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

Time and type of cryAnxious bitter piteous hysterical paroxysmal whimpering violent sobbing etc

Few other questions

1 Does the child apologise for hisher mistake (Does he say ldquosorryrdquo) or wonrsquot apologise

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom51

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 52: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

2 How does the child react when parents pay attention to other children

3 Does heshe share their things with others

4 How does the child keep hisher things in order or careless throws it around breaks it

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom52

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 53: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

5 How particular is the child about cleanliness of hisher clothes amp surroundings

6 Is the child obstinate What if you do not fulfill hisher wish

7 Does heshe listen to parents follow their orders

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom53

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 54: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

8 How does the child react when hugged kissed

9 Hobbies amp what games does heshe play and why

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom54

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 55: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

10 What is heshe scared of Any phobias

11 Does he manipulate if yes give egs

12 Is heshe revengeful if yes give egs

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom55

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56

Page 56: Kavitha Kukunoor BHMS, CCH, RSHom(NA), FRHS Client_Child Full_Case...  · Web viewKavitha Kukunoor CCH, RSHom(NA), BHMS. Homeopathic Consultant. ... A Homeopathic remedy is mainly

13 Favorite cartoon

14 How does heshe react when others are sad or ill or crying

15 Any symptoms which you consider as unique about your child

Thank you for your patience amp co-operation We wish to serve you better

SAI HOMEOPATHIC CONSULTING

Kavitha Kukunoor BHMS CCH RS Hom (NA) FRHS State (India) License Regd No 348 Certified Classical Homeopath Our ref no Date

AGREEMENT FOR HOMEOPATHIC TREATMENT FORM

(BLOCK LETTERS PLEASE) FIRST NAME ________________________________________ LAST NAME __________________________________________ FULL ADDRESS _____________________________________________________________ ______________________________________POSTCODE_________ ___ TELEPHONE (HOME) ________________ MOBILE _________________ (WORK)________________E-MAIL _____________________ DATE OF BIRTH AGE ________________ _ ________ OCCUPATION ________________________________________________ BIRTH PLACE ________________________________________________ MARITAL STATUS (CIRCLE ONE) SINGLE MARRIED LIVING PARTNER SEPARATED DIVORCED OR WIDOWED LIVE ALONE LIVE WITH ______________________________________

Kavitha KukunoorClassical HomeopathEmailInfokavithakhomeocom56


CCH Education Deck

CCH Education Deck

Education
Foreword - CCH

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Documents
AS PER THE - homoeopathy.dypvp.edu.in · 3 Homoeopathic Pharmacy First BHMS At the end of first BHMS 4 Organon of Medicine with Homoeopathic Philosophy First BHMS, Second BHMS, Third

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BHMS 2015 Strategic Plan

BHMS 2015 Strategic Plan

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Cch India32

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I BHMS 2020-21 ADMISSION LIST

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Revista 84 CCH

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First Aid in a Pinch! - JoetteCalabrese.com · Joette Calabrese, HMC,CCH,RSHom 716-941-1045 First Aid in a Pinch! Wouldn’t it be a relief to know that as quickly as an emergency

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ssuhs.inssuhs.in/download/rates_of_exam_fees.pdf · Examination BAMS EXAM BANIS Prof BALMS 2nd Prof BAMS (Final) BHMS EXAM V BUMS Prof. 2nd BHMS Pror BHIMS Prof 4th BHMS (Final) Particulars

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HOMEOPATHY FOR COLIC - National Center for … Center for Homeopathy Monthly Webinar Series Presents: HOMEOPATHY FOR COLIC With Kim Kalina, CCH, RSHom (NA) Core Faculty, Teleosis Homeopathic

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Syllabus – BHMS (2015)

Syllabus – BHMS (2015)

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CCH Test Bank

CCH Test Bank

Documents
Cch slibrary

Cch slibrary

Education
Chicken Pox Essentials - Powers of Homeopathy...Chicken Pox Essentials Helping Children Heal With Homeopathy Information and Resources researched by Donna Powers, RCSHom, CCH, RSHom

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Workpapers - CCH

Workpapers - CCH

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Mbbs - Bds - Bams - Bhms

Mbbs - Bds - Bams - Bhms

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Indian BHMS I Syllabus

Indian BHMS I Syllabus

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Annual BHMS Exam Details

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SYLLABUS: FIRST B.H.M.S. EXAMINATION (DIRECT ...files.stupidsid.com/Syllabus/Medicine/muhs/bhms/bhms...SYLLABUS: FIRST B.H.M.S. EXAMINATION (DIRECT COURSE) II) Homoeopathic Pharmacy

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Kate Birch RSHom(NA), CCH. Natural exposure to disease Cell-mediated immunity Antibody production Life long immunity

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CCH Election

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Dr.ACHMCH, Bhubaneswar · 1 1010440259 simran mallik bhms 70.0 ge web - 2 1030540183 sruti sourav behera bhms 84.0 ge web - 3 1030370018 debajyoti padhi bhms 108.0 ge web - 4 1030540309

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