Homeopathy Questionaire

Presenting condition(s) (in detail)

When it started?

Any factors that may have contributed to the onset of the condition?

What makes it better that you are aware of?

What makes it worse that you are aware of?

Is there a time in the day when it is worse?

Are there any activities that affect it?

Any other symptoms at all , even unrelated?

Sleeplessness?

Any past medical history ( full details )?

Think about any patterns of headaches, digestive problems, asthma, skin conditions etc.

Birth Weight

Childhood ailments

Which vaccinations?

Any reactions to vaccinations or any medical drugs?

Any known allergies?

Any injuries?

All other medical conditions

Any cold sores?

Any warts?

Any mouth ulcers?

Any family history ( cancer, heart disease , diabetes ,asthma etc ) ?

Include Grandparents, parents and siblings

What are your life long Favourite foods ?

Favourite meat?

Don’t like meat?

Do you prefer meat to fish?

Any foods or flavours you dislike?

Are you thirsty ?

Yes

What do you drink?

Any alcohol ? – obviously does not apply to children!

Any smoking ? - ditto

Are you more likely to get too hot or too cold?

Do you perspire much? Where from?

What is your best time of day?

What is your worst time of day?

Sleep pattern

Any problems with sleep?

How do you lie in your sleep?

Any memorable dreams?

Any recurring dreams?

Do you have any nightmares? If so , what of?

Any fears (dark, heights, spi-ders, thunderstorms, fairgrounds, tunnels, flying etc )?

Any major traumatic events in your life?

Temperament / Character:

please write me a detailed description of yourself

Think of things as well like :

Are you tidy / organised?

What irritates you ?

Ambitions?

Hobbies? If you like to read, listen to music, watch films etc then what type?

What do you like to do socially ?

Do you enjoy your own company?

Are you someone who shares your worries or do you prefer to keep them to yourself?

Mood swings? Do you get depressed, etc?

What makes you cry?

Relationships with your parents, siblings, partner, chil-dren?

Any bereavements?

Do you enjoy your work?

Please tell me as much as you can about your personality...

If there is anything else that you think may be relevant, please add

Thank you so much, and please return via e-mail

	Yes	No
Salty?
Spice?
Vinegar?

	Yes	No
snore?
talk? (in sleep)
walk?
grind your teeth?

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Homeopathy Questionaire

Presenting condition(s) (in detail)

Temperament / Character: