For Children Children's Diagnostic Form Please provide complete and accurate information about the child so that a better assessment and appropriate guidance can be provided. Basic Information Name Father's Name Date Email Phone or Mobile Number Age in Months Number of Other Children Country City Complete Street, Neighborhood, or Village Address Milk and Diet Does the child vomit milk? YesNo Is the vomited milk curdled? YesNo Was the child breastfed? YesNo If the child was breastfed, for how long? Is the child also given solid food along with breast milk? YesNo Describe the child's diet Digestion, Stool, and Urination Does the child suffer from constipation? YesNo Does the child experience gas or abdominal bloating? YesNo Is the stool usually loose or hard? LooseHard Is there any mucus in the stool? YesNo On average, how many loose stools occur in 24 hours, and what color are they? Describe the urine, including its amount and color Physical Condition and Sweating Does the child develop diaper rash? YesNo Is the child's body usually cold or warm? ColdWarmNormal Does the child experience cold sweat on the forehead? YesNo Does the child's head sweat excessively? YesNo Describe any unusual symptoms related to the body, skin, sweating, or temperature Birth and Medical History Has the child ever had pneumonia? YesNo If the child had pneumonia, when did it occur? Were there any notable complications during birth? Was the child delivered by Cesarean section? YesNo Has the child had any serious illness in the past? YesNo When did the current illness begin? Describe the symptoms in detail Treatment, Medication, and Allergies Briefly describe the treatment received so far and its outcome. Which medicines were used, and for how long? Does the child have any allergy or reaction to a medicine, food, or other substance? Is anything specifically avoided? Provide any additional information about the child's illness Important Notes for the Patient What is your estimated budget for one month's medication? Upload the child's medical reports, if available I confirm that I have completed this form carefully, thoughtfully, and responsibly.
