Consult Online

Questionnaire for Online Homoeopathic Consultations

How would you like Homoeopathy to support you?

This questionnaire is to help give me a clear picture of you as a person and how you want Homoeopathy to support you.

Please print off, or copy/paste into a Word Document, and fill out the questionaire. When you have filled out the questionaire please email it to me and I will email you back if I need to ask you to clarify any information I am not sure about. I will then contact you for payment details and once this is finalised,  I will send you your remedies and treatment programme.

 All your details are totally confidential. I look forward to working with you. Thankyou.

Name:

Sex:

Address:

Date of birth: Age:

Height, Weight and Build:

Occupation:

Marital / Relationship Status:

Email:

Land line Phone no:

Mobile no:

What is your main complaint?

If there are more than one issue you would like to address please list them in importance for you. These do not have to be medical problems; it may be sleeplessness, lack of energy, thoughts that affect your quality of life. What makes you and or the situation better or worse such as, it comes on in the evening or hot showers relieve the tightness. Please give as much detail as possible, such as time of day/year or situation that the issue occurs in and how you experience it. Please describe for example, the pain as being sharp, throbbing, like a splinter. Please use your own words. If you find that it is difficult to describe you issue, that is fine just give it a go and do what you can.

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Can you remember how or when these problems started? What happened in your life around the time that the issue began? What do you think caused your issue? Past history is invaluable in homoeopathy to understand you and your storey.

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Energy. Can you give a description of your energy throughout the day? Such as waking tired, or a lull around 3pm or a rise in activity after 9.00pm. Please state times rather than using words such as “evening”

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Sleep and Dreams. Please describe your sleep patterns, giving times for going to bed and waking. List any preferred sleep positions, body temperature in bed, dreams, nightmares and whether these are recurring. Can you describe the feeling of the dream and if you can associate the dream to any situation in your life.

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Appetite: List your meals through the day and their contents. List any likes, dislikes or reactions to certain foods.Mention your hungriest time of day. Do you like warm or cold foods, are you quick to be satisfied or do you graze all day?

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Digestion: Give any details about wind, indigestion, bloating, odours, pain and how it effects you and what foods you have found are the triggers if you know.

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Thirst: List drinks throughout the day, preferred drinks, dislikeable drinks whether you sip or gulp or drink normally.

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Bowel: Describe the function of your bowel habits. Is it regular each day? Any diarrhea or constipation, and when this occurs. Any odours, consistency, pain, bleeding?

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Urine: What is the frequency, odours and colour? Any pain and when, or bleeding? Do you need to get up at night to go to the toilet?

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Perspiration: Please note any variations in perspiration on areas of the body, whether it is oily, staining and when this occurs

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Skin: Can you tell me about your skin, any rashes, warts, moles, pimples and a history of complaints related to the skin. What seems to aggravate or relieve your skin issues? How are your nails? How is your hair? Do you have any excess on your body or balding or greyness?

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Teeth: Please let me know if you have had any issues with your teeth, braces, root canals or any problems

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Back and joints: Do you have any aches and pains? Please describe the type of pain, where does it originate and/or extend to? And any history associated with this.

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Body temperature: Are you a hot or cold person? Do you tend to wrap up, wear t shirts in winter, or regulate with the changes in temperature?

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Sexual Activity: Are there any issues with your sexual life?

What method of contraception if used and for how long?

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Environment: Can you tell me if there is anywhere that you feel improved or worse when you are there, such as storms, the beach, cold drafts, winds, summer, winter, spring?

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Emotionally: How would you describe yourself at the moment and in relation to your complaints? Happy, sad, anxious, depressed, contented?

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Fears and Joys: Please talk to me about you concerns, worries and fears?

What provides you with joy, pleasures in life and hobbies?

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Your past history of your life and health: Please tell me about your life and history.

Include history of childhood illnesses and events that stand out for you, migrations, and deaths in the family, marriage break ups and accidents.

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Your family history: This includes brothers, sisters, mum, dad and grandparents. It may also include aunties, uncles and cousins as any illness is important to note.

It is helpful to note what they have died of, or has there been some long term or traumatic  situation for them.

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Vaccination /immunization history. It is important to include all these from birth onwards. Please remember to include any you may have had for travel, work, or from being in the armed forces.

Have you had any reactions to these?

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For Women. Can you please describe your menstrual cycle? Its regularity, duration, flow, clots, pain or cramps? Also PMS or other symptoms associated with the period ie. Headaches, constipation, tiredness, mood swings or libido function.

Please tell me if there are any issues with your breasts, breast feeding, pregnancies ovulation, menopause in as much detail as possible?

Is there are Leucorrhoea discharge and if so what is its nature, colour, duration, time of month that it occurs, consistency, odours etc.

Please fill me in on how many births and pregnancies and any events connected to these. Can you tell me how your puberty, menopause was/is?

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For Children: Whoever it is that is filling this out for a child please do so including age of mile stones such as crawling, walking, teething, talking, weaning, toilet training, how the first days of school went? What if you know was the pregnancy and birth like for the mum.

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For Men: Last but not least. Please include any issues with urination, libido and

Prostate issues

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Additional. Please inform me of any information that does not fit in to any of these categories that you feel it is important for me to know?   Thank you

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Once the questionnaire is completed please send it to me. Sometimes I will need to ask further questions to assist me in reaching a decision about how to proceed with remedies and protocol that will be best suited to you.

Once you have had your first consultation there is a gap of 3 or 4 weeks before a further consultation is needed.

I am available for any queries by email at no extra cost.

Usually we need to consult with you about your health and its direction and developments between 1 and 4 times before you are well on your way to good health.

These consults are usually monthly. This is negotiated as we go along.

Thank you.