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Consultations Form

This questionnaire is to enable professional, appropriate and effective homeopathic treatment over the internet.

If you are new to the science and practice of homeopathy, could you please answer all the questions in as much detail as possible, how the symptoms really affect you on an emotional and physical level.

If you haven't booked a time and date already then please "Click Here" and make an appointment.

If you have any questions please Contact Us

 

    PERSONAL INFORMATION

    MaleFemale

    SingleMarriedSingle ParentWidow/Widower

    CHIEF COMPLAINT TODAY

    PAST MEDICAL HISTORY

    FAMILY MEDICAL HISTORY

    ALTERNATIVE DIAGNOSIS

    PERSONAL HISTORY

    MENTAL EMOTIONAL SYMPTOMS

    PHYSICAL GENERALS

    TIME

    WEATHER

    TEMPERATURE

    POSITION

    GASTROINTESTINAL SYSTEM

    MEALS AND DRINKS

    MEALS AND DRINKS

    SLEEP

    FOR WOMEN ONLY

    FOR MEN ONLY

    SKIN AND NAILS

    Skin symptoms- please describe them and attach a picture if relevant.

    SENSES

    PAIN




     
    Here is examples of how the pictures should look.:

     
     
     

    Right Eye

    Left Eye

    Tongue