Pre-appointment questionnaire

Welcome to Virtual Homeopathy
A charitable clinic run by Homeopathy UK

Thank you for making your first booking at Virtual Homeopathy run by Dr Gabriella Day, MFHom.

Consultations and prescriptions:
The clinic offers up to five free homeopathic consultations, including the initial appointment and your initial prescription. You will need to meet the cost of subsequent prescriptions which are typically £7-£15. The pharmacy preparing the remedy will call you for payment details a day or two after your consultation.

Cancellations:
Demand for appointments is high, so if you are unable to keep your appointment, please give us as much notice as possible – and by 1pm the day before the appointment at the latest - so we can offer it to someone else. Repeated cancellations or rearrangements may result in your removal from our clinic list.

Pre-appointment questionnaire
Please complete the attached questionnaire and bring it to your appointment, or email it before the appointment to virtualappointments@homeopathy-uk.org. (to send the form online press the submit button at the bottom of the page)

Please make a note of/bring any medication, supplements or remedies that you take regularly to your consultation.

If you have any questions prior to your appointment, you can contact the clinic on 0203 640 5903 option 1.

Consultations are provided free of charge but we are very grateful for any donations to support the work of the clinic.

Thank you and we look forward to seeing you soon.
Pre-appointment questionnaire

To be completed before or at the patient’s current visit
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Telephone*
Please enter a valid phone number.
Email*
example@example.com
Date of birth*

DayMonthYear
Age*
Appointment Date*

MonthDayYear
Why did you come to the clinic today?*
Please note your current health complaints and rank them in order (1 being the most important)?*

Do you have one of the following conditions:*

	No	Yes	N/A	Comment
High Cholesterol Problems with medication(s)?
Diabetes Problems with medication(s)? Most recent home glucose readings:
High Blood Pressure Problems with medication(s)? Most recent home blood pressure readings:
Depression Problems with medication(s)? Any suicidal thoughts?

Have you been to the Accident & Emergency Service, hospital or any other provider in the past year? *

Alcohol*

	Never	Monthly or less	2-4 times per month	2-3 times per week	4 or more times per week
How often do you have a drink containing alcohol?

	0	1 or 2	3 or 4	5 or 6	7 to 9	10 or more
How many standard drinks containing alcohol do you have on a typical day?

	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often do you have six or more drinks on one occasion?

Caffeine*

	No	Yes: How often?	How much?
Do you consume any caffeine?

Exercise*

	No	Yes: How often?	How long?
Do you exercise?

Smoking*

	No	Yes: How often?	How much?
Do you smoke?

Birth control*

	No	Yes: What method?
Do you use any form of birth control?

Medication adherence*

	No	Yes: Describe.
Do you experience any difficulties or issues with your medication?

What medicines are you taking and for what conditions?*
What is your family medical history?*
Do you have any allergies?*
Have you recently developed any reactions to any of your medications?*
Have you had any health problems after which you have never been totally well since? Which ones?*
How would you describe yourself? E.g. tired, go-getter, happy, withdrawn, confident, etc. Use as many adjectives as you would like.*
Are you experiencing any of the following?

Abdominal painAnxietyBlood in stoolsBloody urineBreast massBruisingChanging moleChest painConstipationCoughDiarrhoeaDouble visionEar painEnlarged lymph nodesExcessive thirstExtreme fatigueFallingFeverFrequent urinationHay feverHeadacheHeart palpitationsHeat/cold intoleranceImpotenceIrregular mensesJoint painMuscle weaknessNauseaNumbnessPainful urinationRunny noseShortness of breathSore throatSudden vision lossSuicidal thoughtsUnusual bleedingVomitingWeaknessWeight lossWheezing
Do you have any other concerns? *
FAQs

When are appointments available?

Appointments are available on the last Wednesday of each month, 9.30am-12.30pm and the second Monday of the month 3.00-6.00pm via Zoom or Skype.

How long are the appointments?

Your initial consultation will take an hour. The clinician will ask a lot of questions about you and your particular health issue. Follow up appointments are 30 minutes and will give you a chance to update the clinician on any changes to your health.

How much are the appointments?

Appointments are free of charge but patients are encouraged to make a donation to help secure the long-term future of the clinic.

How do I book my appointment?

To book appointments please visit https://homeopathy-uk.org or call 0203 640 5903, option 1, option 1
POST APPOINTMENT INFORMATION SHEET

Taking your homeopathic medicine:
- Read the instructions carefully.
- Take nothing by mouth 30-60 minutes before and after taking your homeopathic medicine. Your mouth should be free of any taste from food, drinks, toothpaste, breath mints, mouthwash, etc.
- A dose of homeopathic remedy is usually 1-2 tablets or pills, 1 powder, 1-2 drops or liquid potency or about 100 of the tiny poppy seed granules (for these it does not have to be precise). The dosage for you should be clearly indicated on the label,
- Do not touch the remedy by hand; dispense them from the bottle into the cap and then from the cap into your mouth or under your tongue.
- Only take the exact number of doses of your remedy that your practitioner has prescribed. This will be indicated on the label and if anything is unclear contact the pharmacy before taking any of the remedy.
- Protect the medicine -- do not expose it to moisture, direct sunlight, or heat over 30 degrees (for example, in your car during summer!). Store the remedy in a cool, dry place away from bright light and strong odours such as essential oils or cleaning solutions.
- Discard any contaminated remedy. If some gets spilled, throw it away; do not return it to the bottle. Keep remedies in the original container in which they were dispensed and not transfer to any other container.
- Don’t be over stimulated with caffeine. Coffee produces its own symptom complex which can be confusing.
- Use toothpaste that is either non-mint or at least not strongly mint flavored. (Leaving the cap off the toothpaste tube will help reduce the strong flavoring).
What to expect:
- The remedy is only a catalyst, it’s a “starter”; your immune system takes it from there!
- The first thing to change will be your mental/emotional state (and you should feel like you have more energy and a sense of calm; in fact, you might fall asleep, or feel like you want to fall asleep; children, babies, usually do fall asleep after a remedy, it’s very common and we generally count it as a sign that the remedy chosen was correct)
- Next will be the physical changes and they will be dealt with in a certain order, not all at once and, when an issue is resolving, it moves out, like the ripples in a pond, rather than simply disappearing! Mental disturbances, for example, may disappear and be replaced by a fever or a “cold” (don’t run and get antibiotics or paracetamol/ibuprofen etc. because you will just suppress your case back to the mental plane); so, it’s really important to be able to properly judge just what a new “complaint” means after a remedy.
- If you notice no improvement or change this will be discussed at your follow up appointment.
When to contact your homeopathic practitioner:
- you notice an aggravation of your symptoms that is not tolerable and does not settle within a few days
- if new symptoms appear that you are unable to tolerate until your next appointment
- old symptoms return that are not short lived or become intolerable and you do not feel able to wait until your next appointment
Useful contacts for:
- Questions about your medicine, contact a homeopathic pharmacy and tell them you are a patient of the clinic.
- Freeman’s Homeopathic Pharmacy:
  0141 644 1165 or pharmacy@freemans.scot
- Helios Homeopathic Pharmacy:
  01892 537254 or pharmacy@helios.co.uk
- Dr Gabriella Day (non-urgent) – email virtualclinic@homeopathy-uk.org
- Booking another appointment– https://homeopathy-uk.org/
- Emergency homeopathic advice – Homeopathy Helpline 09065 343404 (costs £1.53 per minute)
- Health query non-urgent – dial 111 for 24 hour NHS advice or contact your registered GP Practice
- Health emergency – dial 999
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Consent Form
I, Name of patient or legal Guardian:

First NameLast Name
I give permission to share details of my symptoms with other professional homeopaths or a supervisor if my (or my child’s) best interests be served by such a consultation. My right to privacy will be protected by withholding my name and any other identifying information. *

Yes, I give permissionNo, I do not give permission
Date*

MonthDayYear
Appointments | 0203 640 5903 option 1| virtualappointments@homeopathy-uk.org

This is a charitable clinic run by Homeopathy UK; registered charity (number 235900) Registered Charity No: SCO49515– Scotland.| https://homeopathy-uk.org | 020 3640 5903
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