PERSONAL INFORMATION

Name (required)

Surname(required)

Country:

Email (required)

Telephone Number

Date of birth (dd/mm/yyyy)

MaleFemale

SingleMarriedSingle ParentWidow/Widower

Weight (KG):

Height (M):

What Allopathic (Conventional) medicines are you currently taking? (Please be as specific as possible)

Previous homoeopathic remedies taken and potency? (Please be as specific as possible)

Surgeries: Date, reason (Please be as specific as possible, metal implants, dental surgeries, ... )

CHIEF COMPLAINT TODAY

Reason for consultation (Please be as specific as possible)

When did your symptoms first start:

Any possible cause. (accident, worry or stressful event, infection,) please describe anything that you feel is associated with the current symptoms that is unusual, rare or peculiar which you wish to add.

MODALITIES (time of occurrence, position or side of the body affected, food, description of pain, extension of pain to other parts of body)

What aggravates the condition?

What improves the condition?

PAST MEDICAL HISTORY

Any reactions to vaccination (crying, abscess, ADHD, autism, repeated infections?

Any traumas that you have experiences in the last year?

Childhood diseases (measles, mumps, chicken pox, german measles)

Last high fever (date and temperature)

Number of courses of antibiotics taken in childhood and adulthood

Pregnancies? Miscarriages (Please provide dates)

FAMILY MEDICAL HISTORY

Do any of your family members, including your grandparents have any diseases such as Hypertension, Diabetes, Cancer, Arthritis, Constipation, Depression, Anxiety, Parkinson’s, Alzheimer’s, Cardiovascular disease

ALTERNATIVE DIAGNOSIS

Has a diagnosis been made for your condition, by whom, what is the diagnosis? Was any other advice given?

PERSONAL HISTORY

Please provide detail of your medical history since childhood as far as you can recall, inc accidents, hospitalizations, medications etc. (Date/Age, Condition, Medication used)

MENTAL EMOTIONAL SYMPTOMS

Describe any important event that affected you greatly

How did it affect you in the past, How does it affect you now?

Discuss your concentration ability and memory for certain events?

Do you have emotional indifference to: loved ones, pleasure, everything or anything else?

Does music have an influence on you?

Do you have a suicidal disposition in any way?

Do you suffer from any fears?

Do you suffer from anxiety?

Can you briefly describe your home circumstances and important relationships?

PHYSICAL GENERALS

How do you react to temperature?

Describe your sleeping habits

What are your food desires and or aggravations, what foods do you crave and what foods do you loathe, what foods make you feel good and what foods make you feel worse?

What drinks do you desire?

When you drink, do you sip or gulp it down?

What are your appetite habits?

TIME

In what season do you feel less well?

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

WEATHER

How do you stand the cold/hot weather?

How do you stand the dry/wet weather?

What do you feel when exposed to the sun/wind/snow?

How does the change of weather effect you?

TEMPERATURE

How do you respond to warmth in general? (Warmth of the bed, warmth of the room?)

How do you respond to extremes of temperature?

How often do you catch a cold in winter and other seasons?

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

POSITION

What position do you prefer, find most comfortable- sitting, standing or laying down?

GASTROINTESTINAL SYSTEM

Do you have regular bowel movements?

Are they dependent on what you eat?

How does your emotional state affect your bowel movement (stress, worry)?

Do you suffer from bloating, belching or heartburn? When? What aggravates the symptoms, what do you do to prevent or improve the symptoms?

Any symptoms associated with bowel condition? (insomnia, fatigue, irritability, brain fog, PMS)

Do you suffer with haemorrhoids or bleeding with stool?

MEALS AND DRINKS

How do you feel before / during/ after meals?

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

What are the foods that make you sick and why?

What about pastry and sweets?

What about sour or spiced foods?

What about rich or greasy food?

What about thirst and what you drink?

How much salt do you need for your taste? (Do you add salt to food at the table?)

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

MEALS AND DRINKS

Do you smoke? Cigarettes, dagga, other? How much a day or how often?

Do you or have you partaken in any recreational drugs? (How frequently, duration)

Are there any substances/actions you suspect you may be addicted to? Drugs, cigarettes, medications, gambling, sex, alcohol, Other?

SLEEP

Do you struggle to get to sleep?

Do you wake up frequently? (Time, restless, overactive mind, worries, pain)

In what position do you sleep in?

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?

FOR WOMEN ONLY

Have you ever been sexually molested or abused? Is that event affecting you still today?

At what age did your period begin?

How frequently do your periods come? Please describe their duration, abundance, colour, and odour.

During which time of the day does it flow most?

Please describe any significant details that may be relevant?

Do you suffer from pain during your period? When, type, associated symptoms, severity?

Do you have vaginal discharge (colour, itchy, when it appears, what aggravates it, what improves it.

Describe yourself before, during and after your period? (behaviour, feelings, character)

Do you suffer from breast tenderness, swelling or lumps? When? Symptoms associated with it?

Are you sexually active?

Do you have pain during intercourse?

Do you enjoy sexual intercourse?

What is your sexual desire or appetite like?

Do you struggle with hot flushes? If so where do you feel the heat? And when?

FOR MEN ONLY

Do you suffer from pain during urination?

Do you have to get up at night to urinate? Now many times?

Are you able to achieve suitable erections for intercourse?

Do you suffer with urinary burning or discharge? Is it blood stained, colour

Do you have a good libido or sex drive?

Do you struggle with back pain especially after intercourse?

SKIN AND NAILS

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

Are they dry, moist, oozing, colour, itchy?

What is the nature of the discharge?

In what part of the body did it start?

Did it start after a vaccination or other event?

Do you or have you suffered with acne, boils or supperative tendencies?

Do you have a tendency to suffer with warts, tumors, eczema, psoriasis, erruptions or blisters?

Is your skin generally dry or greasy?

Do you sweat easily? From where? When?

Do you have any ingrown toenails, or hangnails?

Does your nails have vertical/ horizontal grooves or white specs

Does your nails become brittle?

SENSES

Any problems with your senses? (hearing, vision, smell, taste)sinus, headache?

Any problems with your mouth or dental problems? (mouth ulcers, abscess, grey dental fillings, root canals)

PAIN

Do you feel any pain?

What is the nature of the pain you experience? (Burning, aching, numbness, throbbing?)

What makes the pain better or worse?- Temperature, movement, pressure or position

Do you suffer with involuntary tics or twitches?Where and when?

Do you have a tendency to sigh?

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