Patient Questionnaire - Homeopathy by CLondon

Patient Questionnaire - Homeopathy by C London

Name

Address

DOB/Age

Email

example@example.com

Relationship status

Occupation

Children, if so ages

Anything you say in this questionnaire is Private & Confidential between me and you.

PRIMARY REASON FOR SEEKING TREATMENT (in detail) Include how the condition started and the original symptoms, then how the condition has progressed.

When did the condition start?

Any factors that you think 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?

Time of day it is better or worse: (am, pm, after midnight etc.)

Any activities you find effect it?

Have you had any scans, blood tests, if so, what were the results?

Any other symptoms at all, even if you think unrelated, they could be relevant

MEDICAL HISTORY (Think about patterns of headaches, colds, digestive problems, asthma, skin conditions, hayfever, food allergies)

Birth weight (if known)

Childhood Ailments - age you were if known:

Vaccinations - including travel jabs & year you went & CV vaccine/dates

Any reactions to medical drugs or vaccinations of any kind?

Any known allergies

Any injuries

Any other medical conditions

Do you get coldsores?

Do you get mouth ulcers?

Do you get warts?

Are you susceptible to cold and coughs do they linger?

Are you on any medication, conventional or alternative?

Are you aware of any side effects?

Please describe any Traumatic event in your life (Bereavements, injury, stress, big changes, shocking events, witnessing trauma, job loss etc. & year it happened) Have a good think about this question, and please do give as much detail as possible.

FAMILY HISTORY

Information about the health of your blood relatives, whether they are still alive or have died, is of value to a Homeopath. Please give details about any serious diseases, history of alcohol/drug addition, epilepsy, Down's syndrome, behavioural problems, and any unusual conditions. Please give cause of death to those who have passed & the age if known. (include - cancer, heart disease, diabetes, asthmas, additions, auto immune)

Mother

Father

Grandmother on both sides

Grandfather on both sides

Aunts on both sides

Uncles on both sides

Brothers on both sides

Sisters

Children

What are your lifelong fav foods?

Favourite Meat?

Do you prefer Meat or fish?

Any foods or flavours you dislike? (e.g: salt, sweet, spice, vinegar)

What do you like to drink? Tea, Coffee, juices, water?

Any foods or flavours you like? (e.g: salt, sweet, spice, vinegar)

Are you a thirsty person?

Do you smoke? Cigarettes a day?

Do you drink alcohol? Units per week?

Are you likely to get too hot or cold?

Do you perspire? If so, where?

What is your best time of the day?

What is your worst time of the day?

Do you have any fears? (dark, spiders, heights, flying, needles, tunnels, etc.)

Please describe your sleep pattern?

Do you have problems sleeping?

Sleep Walk?

Grind your teeth at night?

How do you lie in your sleep?

Dreams, any reoccurring?

Please write a detailed description of yourself:

are you tidy / organised?

What do you worry about?

what irritates you?

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

ambitions? This can be anything

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?

Any general fears?

Have you ever been affected by abuse of any kind, at home or in the workplace?

Relationships with your parents, siblings, partner, children?

Any bereavements?

Do you enjoy your work?

Do you feel that you are doing a job that is right for you?

Please tell me as much as you can about your personality especially if you feel they may negatively affect your health?

Anything new you may wish to share since starting the questionnaire- enough though it may not seem relevant.

Lifestyle & General