Pre-appointment questionnaire

Welcome to Liverpool Homeopathy

A charitable clinic run by Homeopathy UK and the North West Friends of Homeopathy

The clinic offers up to five homeopathic consultations including the initial appointment.

Consultations are provided at the very low cost of £20 for an initial consultation and £10 for a follow-up. Payment is needed prior to the appointment to confirm the booking. The fees only cover administration costs for running the clinic. The clinic will not function in the long term without donations and for this reason we encourage all that can, to make a donation toward their consultation. Details of how to make a donation will be provided to you at the end of your appointment.

We aim to provide all our patients with the best possible service and to achieve this we need your cooperation. The demand for appointments in our clinic is extremely high as the clinic is run on a charitable basis.

Non-attendance and cancellations at short notice may mean another patient who wants to attend the clinic is unable to due to limited availability. If you are unable to keep your appointment, please make every effort to cancel it well in advance, so that it may be offered to someone else.

Please contact the clinic by 1pm on the Tuesday before your appointment at the latest if you need to cancel. Failure to attend you appointment on the day, repeated cancellations or rearrangements may result in your removal from our clinic list.

After the consultation the homeopath will prescribe a homeopathic medicine. It will be sent by post to you. It usually arrives within two days. You will be invoiced for the medicine and will need to pay for the prescription. The amount is usually between £7- £18 plus postage and packaging.

Below is a pre-appointment questionnaire that needs to be completed prior to your initial appointment.

The clinic is attempting to run a paperless system. If you are able to email the completed questionnaire back to the clinic the week before the appointment, we would be very grateful.

Please email it to Liverpoolappt@homepathy-uk.org or press submit when you complete the questionnaire online.

Please ensure you include your full address and postcode so that prescriptions can be sent quickly and efficiently to your door.

If you have any questions prior to your appointment please contact the clinic on:

0203 640 5903, option 1, option 1.

Below this section you will find information on how to take your remedies and useful information and then a pre-appointment questionnaire which we require at least 48 hours in advance of your appointment.

Thank you and we look forward to seeing you soon.

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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, tooth paste, breath mints, mouthwash, etc.
A dose of homeopathic remedy is a few (~10) of the poppy-seed sized pellets, or 1-2 of the larger pillules. You can shake the prescribed number into the remedy bottle cap.
Do not touch the pellets by hand; toss them from the bottle cap onto or beneath your tongue.
Unless directed otherwise by your practitioner, only take one dose of your remedy. It acts as a signal to your self-regulating and healing mechanisms, and they will be responding even if you do not repeat the remedy daily.
Protect the medicine -- do not expose it to moisture, direct sunlight, or heat over 40 degrees (like in your car during summer!). Store the remedy in a cool, dry place away from bright light and strong odours like essential oils or cleaning solutions.
Discard any contaminated remedy. If some gets spilled, throw it away; do not return it to the bottle. Do not transfer the remedy to other containers or bottles that have held homeopathic remedies. These will still have active medicinal properties.
Don’t be over stimulated with caffeine. Coffee produces its own symptom complex which can be confusing. Also avoid energy drinks.
Cut back or eliminate the use of herbal supplements. These are medicinal substances which will mask your symptoms and make homeopathic prescribing more difficult. Avoid the use of camphor, eucalyptus, wintergreen and other strong scents used in products like Vicks Vaporub, Bengay, Tiger Balm, cough drops and throat lozenges, etc. Vitamin and mineral supplements are fine as are other non-herbal nutritional supplements such as fish oil, probiotics, etc.
Use toothpaste that is either non-mint or at least not strongly mint flavoured. (Leaving the cap off the toothpaste tube will help reduce the strong flavouring).

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.
An old symptom might come back. This as a good sign, a sign the remedy is working.
A different symptom you have might become amplified after a remedy.
These are all parts of the healing process.
If you notice no improvement or change this will be discussed at your follow-up appointment.

When to contact your homeopath:

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 -
- Ainsworth’s Pharmacy:
  020 7935 5330 or london@ainsworths.com
- Freeman’s Pharmacy:
  0141 644 1165 or info@freemans.uk.com
- Helios Homeopathic Pharmacy:
  01892 537254 or pharmacy@helios.co.uk
Reaching your homeopath (non-urgent)
- Dr Hugh Nielsen: hnielsen@homeopathy-uk.org
- Emma McEvoy: emcevoy@homeopathy-uk.org
Booking another appointment at Liverpool Homeopathy – please go online to Liverpool Homeopathy Clinic
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

Patient Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code

Telephone*

Please enter a valid phone number.

Email*

example@example.com

Date of birth*

Age*

Appointment Date*

Who is your Homeopath?*

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 any 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 Department, hospital or any other clinical 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 an allergy 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?

Do you have any other concerns? *

We use SurveyMonkey for our Feedback - by ticking the box you acknowledge that your data will be transferred to SurveyMonkey for processing in accordance with their Privacy Policy. To make any changes to the way we use your data, email info@homeopathy-uk.org or phone 020 3640 5903.

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*

Liverpool Homeopathy Clinic is a charitable clinic provided by Homeopathy UK. Homeopathy UK, Registered charity in England & Wales: 235900 and Scotland: SC049515. Company Limited by Guarantee: 102915

Telephone: 020 3640 5903. Email: info@homeopathy-uk.org.