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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
 
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)

Paternal Grandmother (Father's Side)

 

Mother

 

Sibling 1

 
Gender

Sibling 3

 
Gender

Sibling 5

 
Gender

Maternal Grandfather (Mother's Side)

Paternal Grandfather (Father's Side)

 

Father

 

Sibling 2

 
Gender

Sibling 4

 
Gender

Sibling 6

 
Gender
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
 
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

Habits
 
Sensitivities
 
Appetite and Thirst
 
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.

Salty
Sweet
Bitter
Sour
Spicy
Cold Food
Cold Drinks
Hot Food
Hot Drinks
Bread
Red Meat
Fish
Shellfish
Milk
Cheese