1. Personal Details

Gender
Male Female Other 

Marital Status
 Single Married Divoirced Engaged

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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?

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3. Current Symptoms

Please try and describe all the current symptoms in your own words including if possible, the cause. To help you with your response, imagine that you are sitting in front of me and I ask, "So what brings you here today?"

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?

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4. General Symptoms

In which season do you feel less well?

How does fog affect you?

At what time during the day or night do you feel worst?

How do you stand the cold/hot/dry/wet weather?

What do you feel when exposed to the sun?

How does change of weather affect you? What about snow?

What are your reactions to north wind / south wind / the wind in general

How do you feel before, during and after a thunderstorm?

What about warmth in general, warmth of the bed, of the room, of the stove?

What about draughts of air and changes of temperature?

How do you react to extremes of temperature?

What difference do you make in your clothing in winter?

What position do you like best (Sitting / Standing / Lying)?

What about taking colds in winter and in other seasons?

How do you feel standing or kneeling in a church / mosque / synagogue / temple or other place of worship or meditation?

What kind of climate is objectionable to you, and where would you choose to spend your vacation?

How do you keep your window at night?

How do you feel before / during / after meals?

What about your appetite, how do you feel if you go without a meal?

What do you drink and in what quantity? What about thirst? How cold/ icy you prefer your drink?

What are the foods that make you sick and why?

What about wine / beer / coffee / tea / milk / vinegar?

How much do you smoke in a day. How do you feel after smoking?

Are there any drugs which you are very sensitive too or which make you sick?

What are the vaccinations you have had and the results from them?

What about cold or warm baths, or sea baths?

How do you feel at the seaside or on high mountains?

How do collars, belts and tight clothing affect you?

How long do your wounds take to heal, how long do they bleed for?

In what circumstances have you felt like fainting?

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6. Mental and Emotional Symptoms

The symptoms of the Mind are most important and should be carefully considered. Try to give all these symptoms fully as they are very important.

Please note that the questions and language here used are merely suggestive, and are simply intended to lead you to give all your symptoms.

What are the greatest griefs that you have gone through in your life?

What are the greatest joys you have had in life?

In what circumstances have you ever felt jealous?

On what occasions do you weep? At music? At reproaches? At what time of day?

How do you cope with your worries?

What effect does consolation have on you?

On what occasions do you feel despair?

How do you stand waiting?

When and on what occasions do you feel frightened or anxious?

How do you feel in a room full of people or at church, etc or at a lecture?

Do you go red or white when you are angry and how do you feel afterwards?

How rapidly do you walk or eat or talk or write?

What have been the complaints or effects following chagrin, grief, disappointed, love, vexation, mortification, indignation, bad news, fright?

Tell me all about over-conscientiousness and over-scrupulousness, about trifles; some people do not care about too much details and too much order.

What about your memory? Your understanding? Your will? Your concentration? Any tendency to make mistakes?

At what time in the twenty-four hours do you feel the blues, depressed, sad, pessimistic?

In time of depression, how do you look at death?

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7. Food and Sleep

I am looking for clues about you. For example, along with your sleeping patterns I am interested in what you like to eat.

Once a patient said she was hungry in my rooms, and asked if I minded if she ate a snack. I said fine of course. So she took out a tin of Tuna fish and a fork, and ate the contents of the tin. Then she took out another and ate that.

The result of this clue was a diagnosis of a complex endocrine problem, of iron and calcium and iodine, and I knew her remedy. So be sure to tell me what the regular medical people will ignore or scoff at.

What is the kind of food for which you have a marked craving or aversion for?

What kind of food makes you sick or you are unable to eat?

What about pastry and sweets?

What about sour or spiced food?

What about rich or greasy food?

What about thirst and what do you drink?

How much salt do you need for your taste?

Do you have a "salt tooth", e.g. do you add salt to food at the table?

Do you drink coffee / tea / wine / beer or other?

In which position do you sleep? How long have you slept in that position?

Where do you put your arms, and how do you like to have your head?

At what time do you wake up and how do you feel?

When are you sleepy?

What makes you restless or sleepy?

What about dreams?

What do you do during sleep? Talk? Laugh? Cry out? Weep? Be restless? Be afraid? Grind your teeth? Have your mouth open? Have your eyes open?

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8. For Women Only

These questions may appear rather intimate. The answers will help me understand what is troubling you and how to help you. I do not accept the idea that menstrual troubles are something with which you have to live. Many women are told that nothing can be done. I am an optimist and I hope that something can be done, so please answer what you feel are relevant questions.

At what age did your periods begin?

Please describe their duration, abundance, colour, odour

How frequently do your periods come?

At what time in the twenty-four hours do they flow most?

How do you feel before, during and after your period?

Do you take contraceptive pill?

Did you have any hormones therapy ?

which age your menopause started and what symptoms you have/had?

Please describe any other significant details that may be relevant

What about your character, feelings, or behaviour before, during and after your period or after menopause.

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9. Bodily Functions and Discharges

In all of these questions, I am interested in the sensations, their location, what modifies them and what accompanies them.

Do you have Any skin problem or Discharges? Are they dry, moist, oozing? What is the nature of the discharge? Where did they start, and in which part of your body? And when – after a vaccination or after a grief? When do they come and go?

Please detail what is normal and what is unusual or troubling for you in relation to temperature, sweat, mucous, smells, bowels, urine and genital functions.

Any problems of the senses, hearing, vision, smell, taste?

Do you have any problems in your mouth or dental problems?

Do you have any skin problems like eczema, warts, tumours, psoriasis or unexplained eruptions?

Has a diagnosis been made for any condition? If so by whom, what is it, detail any advice given.

Are you taking any homeopathic remedy?

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

Do you take any exercise?

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.

Complete the sentence, "It feels as if ..." about all your pains or discomforts.

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10. Your Personal History

Please detail you medical history since childhood as far as you can recall, including accidents, time in hospital etc.

Please provide as much information as you can regarding the medical history of your immediate family and grandparents.

Can you describe your home circumstances and important relationships?

What are your passions and leisure pursuits?

Are their important aspects of your life that have not been covered?

Thank you for completing the questionnaire.