New Client Questionnaire

So that I am aware of any past and present physical aspects that make you who you are, please take the time to complete the following questionnaire. Each one of these questions has a definite meaning and significance. There is not a single question that is useless or answer that is not important. Even something that you may think is not important could be connected with the complaint you have come to see me about. It could be the most important factor in deciding the correct homeopathic medicine. So please be as open and forthright as possible and give me the fullest available information you can for each question.

Please read each question carefully, think, and if necessary, consult someone close to you and then answer completely.

All the information you provide will remain completely confidential. If you have any questions then please don't hesitate to contact me.

Patient Details

First Name/s

Last Name

Date of Birth

Current Age

Address

Phone (Home)

Phone (Mobile)

Occupation

Doctor / Medical Centre

Referred by

How did you find out about Replenish Healing?

What is your reason for coming (principal complaint)?

Previous and Current Conditions

Please tick the conditions below that you have, or have had, and write the details of any conditions you ticked in the section below.

Please provide further details of any of the conditions ticked above.

Details to include: the condition, age you experienced it, its duration, whether you fully recovered, medicines taken and any additional comments.

Any additional drugs (recreational or pharmaceutical) that you have taken either currently or previously.

Family History

Please provide the following information on your family to the best of your knowledge:

Maternal Grandmother (Mother's Side)

Age (or age when they died)

Health conditions

Cause of death

Paternal Grandmother (Father's Side)

Age (or age when they died)

Health conditions

Cause of death

Mother

Age (or age when they died)

Health conditions

Cause of death

Sibling 1

Gender

Male

Female

Age (or age when they died)

Health conditions

Cause of death

Sibling 3

Gender

Male

Female

Age (or age when they died)

Health conditions

Cause of death

Sibling 5

Gender

Male

Female

Age (or age when they died)

Health conditions

Cause of death

Maternal Grandfather (Mother's Side)

Age (or age when they died)

Health conditions

Cause of death

Paternal Grandfather (Father's Side)

Age (or age when they died)

Health conditions

Cause of death

Father

Age (or age when they died)

Health conditions

Cause of death

Sibling 2

Gender

Male

Female

Age (or age when they died)

Health conditions

Cause of death

Sibling 4

Gender

Male

Female

Age (or age when they died)

Health conditions

Cause of death

Sibling 6

Gender

Male

Female

Age (or age when they died)

Health conditions

Cause of death

What is your position in the family amongst your siblings?

Surgery

Please list details of any past, recent or scheduled surgery

Details to include: Type of surgery, your age at the time, reason for surgery, any complications

Additional Health History

How frequently do you get colds or flu? (Per year, noting frequency and duration of being unwell)

Describe the symptoms (colour & nature of discharge, trouble with breathing, heart palpitations etc)

Do you suffer any difficulties with your stomach or bowel function?

Personal History

Mention from birth to the present day, any important events in your life

for example emotional and physical traumas, heartbreaks, divorces, work-related events, diseases or traumas your mother had while pregnant with you, family stress, death in the family, disappointments etc

Your birth / early childhood

Did your mother have any problems during pregnancy? If so, please give details.

Did your mother take any drugs during pregnancy? If so, what were they?

Was there any difficulty with your birth? If so, please give details.

Did you eat any indigestibles such as a chalk, lime, soil or paper as a child? If so, please give details.

Habits

Do you smoke cigarettes? If so, how many/often?

Do you drink coffee? If so, how much/often?

Do you drink tea? If so, how much/often?

Do you drink alcohol? If so, how much/often?

Do you take sleeping pills? If so, how much/often?

Do you use drugs? If so, what do you use, how much/often?

Sensitivities

Is your body temperature generally cold, average or hot?

Do you notice temperature differences or other sensations in, for example, your feet or hands, or other body part? Is there a particular time?

How are your energy levels during the day, in the morning, midday and evening time?

Which season do you feel best and worst?

How do collars, belts and tight clothing affect you?

Do you prefer mountains, woodland, seaside, hot & dry or humid climates?

Does the wind affect you?

Appetite and Thirst

How is your appetite?

When are you hungry?

What happens if you remain hungry for too long?

How fast do you eat?

How much thirst do you have?

Is there any particular times you are noticeably thirsty?

Food Preferences

For each of the foods listed below please tick in the appropriate like or dislike box, and also tick if the food disagrees with you or you are allergic.