If you would like to be treated homeopathically via email then please copy and paste this questionnaire and fill in as fully as possible and email back to me at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
. This will assist in prescribing more accurately. Thank you.
ON LINE HOMEOPATHY QUESTIONNAIRE
Name
Address
Postal Code:
Landline Phone No: Mobile No:
Email Address:
Occupation:
Status: Married Single Other
D.O.B: Age:
Main Presenting Symptoms:
Which Childhood Illnesses did you have?
Which Immunisations did you have? Were there any reactions to any of them?
Are You on any Medication? If Yes, what and for how long?
Have you had any Accidents? Please state what and when it happened.
Have you had any operations? Please state what it was and when it happened.
Have you ever smoked or taken recreational drugs?
Have you/ or do you currently suffer from any fears or phobias?
Do you suffer from any digestive complaints. Please give details
What do you like to drink? Please include alcohol intake.
Do you suffer from any allergies? (include any foods)
Have you ever suffered from any skin complaints?
FAMILY HISTORY
Please make a list of any illnesses/diseases that are present within your family including mental/emotional disturbances
Parents:
Grandparents
Siblings
Aunts/Uncles/Cousins
All information is given in strictest confidence.
ON LINE HOMEOPATHY QUESTIONNAIRE
Name
Address
Postal Code:
Landline Phone No: Mobile No:
Email Address:
Occupation:
Status: Married Single Other
D.O.B: Age:
Main Presenting Symptoms:
Which Childhood Illnesses did you have?
Which Immunisations did you have? Were there any reactions to any of them?
Are You on any Medication? If Yes, what and for how long?
Have you had any Accidents? Please state what and when it happened.
Have you had any operations? Please state what it was and when it happened.
Have you ever smoked or taken recreational drugs?
Have you/ or do you currently suffer from any fears or phobias?
Do you suffer from any digestive complaints. Please give details
What do you like to drink? Please include alcohol intake.
Do you suffer from any allergies? (include any foods)
Have you ever suffered from any skin complaints?
FAMILY HISTORY
Please make a list of any illnesses/diseases that are present within your family including mental/emotional disturbances
Parents:
Grandparents
Siblings
Aunts/Uncles/Cousins
All information is given in strictest confidence.
Share this post
