Questionnaire - Infants 0 to 6 months
 

Name: Surname:
Date of Birth                       Sex:         
Address:      
 Chief Complaints:
 System affected :
 Symptoms complained: Cough; Colds; Diarrhoea; Vomiting; Eczema; Nappy rash;
                                     Anaemia; Fever;
 How did the complaint start:

After vaccination
After some emotional problem in child
                     Fright   Anger                 other  cause 
After some emotional problem in mother
                     Anger  Joy  Grief      other  cause 
Nothing specific (cant attribute to specific cause)

 Describe the complaints in details:
 

 Medical History:
 Was the patient admitted to hospital before? Yes  No
                    For what complaints: Cough; Colds; Diarrhoea; Vomiting; Fever;
                    How many times:                                               

 Vaccination History:
 

Vaccination

 Complaints after vaccination  
 BCG     Fever  
 DPT: Diarrhoea  
 Polio: Skin complaints  
 Hep Respiratory complaints  
MMR     Neurological complaints  
1st booster        
2nd boster        

Feeding History:
  Breast feeding
  Top feeding...Started at months

 Details of Top feeding
 

 No. of time the infant ask for breast feeding  Day times       Night times
 Can the infant wait for feeding ?    He has to be fed
 Infant takes feeding from  one   / Both breast at a time.
 He gets after feeding small quantity.
 His speed of feeding is  
 
During feeding he   Perspires  
    Goes to sleep  
    Plays and active  
    Goes to sleep immediately after feeding


Obstetric History:

Presentation: Intervention done:
How was the delivery: Birth Weight:
 

Pregnancy History:
 G P A L
 Pregnancy  Planned  Unplanned  Was the child wanted  Unwanted
Desire fro a specific child  Girl  Boy
 Physical Problem during pregnancy 
Mental Tensions during pregnancy:   Anger  Joy  Grief      other  cause 
Other mental tensions:
Finances
                          Husbands Health
Own Health
Discords between other family members
Mothers History:
Specific dreams during pregnancy
Specific fears during pregnancy  
Housewife   Working lady 
When resumed duty  Immediately     Later
Who is taking care of child at home 
 

 
 Constitution
 Weight :
 Height: Normal  Tall  Dwarf Appearance:  Normal  Obese  Emaciation
 Emaciation:

 Perspiration:
 Quantity:  Parts:  Scalp; Neck; Face; Palms; Soles;  

 Sleep Position:
  Abdomen; Back: Changing; Knee-elbow; Sides
 After waking:   Anger Cheerful;  Confused  Dullness;  Lamenting;
  Shrieking;  Weeping

 Thermals:
 Temperature in the chest  Warm   Normal  Cold
 Temperature in the Forehead Warm   Normal  Cold
Temperature in the Thighs Warm   Normal  Cold
 Temperature in the Soles Warm   Normal  Cold
 Temperature in the Palms  Warm   Normal  Cold 
  If you cover the child -- Kicks of the cover immediately;  Keeps the covers
Is comfortable in the covering  Is uncomfortable
 Wrapping up the child  -- Child is comfortable;  Child is uncomfortable

Milestones:
Lower central incisors
Lower lateral incisors
Upper central incisors
Upper lateral incisors
Lower first molars
Upper first molars
Lower cuspid
Upper cuspid
Lower second molars
Sitting
Walking
Talking   --- One words
               ---  Two words
 Mentals:
 Disposition: Nothing specific; 
Cranky and irritable;  Calm and quiet;
nervous and excited; Angry
Haughty; Obstinate
Sociability
 

Play with new toys and are curious to explore it   

Takes time

Immediately

Reaction to new persons (guest) in house

Cry or avoid

Smiles and mix

Guest try to play and pick them.

Cry and refuse to go with them

Smile and willing to go to anyone

When many people are around (gatherings)

Uncomfortable and scared. Clings to mother

Cheerful and playing

Examination

Does not allow

Allow without any fuss

Greets when come in clinic or leave clinic

Does not greet

Says Hi or Bye

Heart rate

Increased

Normal

Pupils

Wide

Normal

Muscle tension

Tensed

Relaxed

Activity
 

Wrapping the Child

Keeps cool

Kicks legs

Covering the Child

Comfortable

Kicks and throws cover

Holding Child in Hand while going out

Mother can hold

Does not remain in hand. Jumps out

When diapers are wet

Calm or mild cry

Scream loudly

Changing diapers and clothes

Child is cool and calm

Moves much and cries

Time to go stools

Predictable

unpredictable

Tags in their clothes

Ok

Reacts

When sleeping – Lights are put on

Keeps on sleeping

Wakes up

When Sleeping – Noise around

Sleep and keeps sleeping

Cannot sleep and wakes

Time to go to sleep

Predictable

Unpredictable

Time to wake up

Predictable

Erratic

While walking – they tumble

Get up and start walking

Scream and Cry

When hungry

Cry

Scream loudly

Time of Hunger

Predictable

Unpredictable

Efforts to reach a toy

Keep trying for 2-3 min

Frustrated easily

 

Destructibility
 If the child is reprimanded/shouted; how does he react
Bites others; Hits others; striking others Spits on others  Kicks others
Punch others 
Pulls own hairs Bangs his own head  Tears his own clothes
Weeps loudly   Weeps inwardly (sulking)  Threatens feels sad
Anger but does not express
Appears frightened  Appears embarrassed  Appears worried  Appears anxious
Laughs
Sensitivity
To Criticism
To Beating of others
To health of others
Weeping of others
To reprimands
Noise
Darkness
Reaction
Loud Noise
Strangers
Separation from parents
Doctors
Animals
Darkness