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Homeopathic Consultation Form
www.wearethereforu.com
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E-mail
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Date of Birth
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Family / home circumstances
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Main Complaint + General Symptoms
Main complaint. When did it start? What makes it better or worse?
Appetite
no appetite, always hungry, quick satiety, overeating, emotional eating...
Thirst
always thirsty, no thirst, desire juice or other...
Food cravings / aversions / reactions
salty, sweet, foods you hate or give you problems
Allergies
animal fur, pollen, spring or summer, skin...
Known Drug Reactions
antibiotics, cortisone, others....
Weather
how the weather affects you
Perspiration
sweating on certain body part, stains which color....
Cold / Heat
always hot, or always cold, or neither, don't like extreme temp. only...
Sleep
quality of sleep, hours, wake up in which state...
Mental & Emotional
Subjective perception / feelings + when did it start?
mental & emotional state: ex. depression, anger, love sick, ...
Behaviors + when did it start?
Example: OCD,
Fears and Phobias
Dark, snakes, spiders, thieves, heights, ...
Memory
Good or bad and since when?
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Physical Body
Scalp, hair, nails
Eyes / Ears / Nose / Sinus
Throat / Glands, etc.
Dysfunction of Sight, Hearing, Smell, Taste
Mouth / Teeth / Gums / Lips, etc.
Head / Neck
Spine / Back
Musculoskeletal / Joints
Chest / Heart / Lungs
Circulatory System / Blood Pressure
Respiration
Stomach / Digestive System
Bowels / Stool
Urinary System / Bladder, Kidneys / Urine
Kidney stones, sand, urine color & smell....
Reproductive System / Genitals
Birth Control
Have you ever used them before?
Period - Menses
Period on time? No. of days. PMS symptoms
Pregnancies
Any symptoms during pregnancies
Your own pregnancy & birth information
C-section or natural birth? Did you get breastfed?
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Timeline
0 - 7 years
8 -14 years
15 - 21 years
22 - 28 years
29 - 35 years
36 - 42 years
43 - 49 years
50 - 56 years
57 - 63 years
64 - 70 years
After 70
Family History
Diabetes, high blood pressure, heart conditions, thyroid, cancer, cholesterol, etc.
Diseases on your mother's side of family
Diseases on your father's side of family
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