1. Personal Details

First Name(s) (required)

Surname (required)

Address (required)

Post Code

Country

Your Email (required)

Telephone

Date of birth

Gender
MaleFemaleOther

Height

Weight

Marital Status
SingleMarriedDivoircedEngaged

Number of children

If you are working, please write you job here

-------------------------------------

2. Reason for visit

I would like to begin with you telling me in your own words what has brought you here today. Please be as general or specific as you wish. Expand these spaces with as much information as you can. I often ask my patients “And what have you been up to?” or “How can homeopathy help you?”. So if you wish just sit back, relax, and write about yourself.

If you prefer, you may answer the questions that follow and come back to this question later. The questions are designed to jog your memory and show you what I need to understand about you. What is your reason for consulting me today?

-------------------------------------

3. Current Symptoms

Please try and describe all the current symptoms in your own words including if possible, the cause.
When did the symptoms begin? Can you suggest some factors that helped create these symptoms?

If this is not the first occurrence please describe any previous problems of this kind.

Please describe anything that you feel is associated with the current symptoms that is unusual, rare and/or peculiar or any other information which you wish to add.

It would also be very useful if you could describe any particular important events in your life. How did you feel about them at the time? Also, how you feel about them now?

Are you taking or ever took any homeopathic remedy?

Please tell me about any conventional medication, herb, vitamin or mineral supplement?

Do you take any exercise?

Do you have any allergy ?

In case you did not mention it above, do you feel any pain?

Is the pain you feel burning, aching, numbness and/or throbbing or other
sensation. Provide any other information.

-------------------------------------

4. Your Personal History

Please detail you medical history since childhood as far as you can recall, like: surgery , vaccinations , any accidents and injury and time in hospital etc.

Thank you for completing the questionnaire.