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Homeopathic Questionnaire Form
                for the Adults

           Please enter your contact Information
          The fields marked * indicate required information
 
*First Name *Last Name
Company Name
Address
City/Town State/Prov/County Country Zip/Postal
Phone No Fax No
*E-mail
Age Gender Date of Birth
Weight Height Regular Pulse rate

 
1. Please, describe in details your personal Health Complains and general Symptoms:

2. Please, specify correctly your recent medical diagnosis (if you were diagnosed). Please, specify if you have any particular abnormalities in your blood test (if you had one):

3.Please, specify medical Treatment(s) which you were taking before (including drugs and procedures). If yes, please, describe how this Treatment(s) affected your Physical and Emotional Health: 

4. Did you have any type of natural (alternative medical) or Professional Homeopathic Treatment(s) before? If yes, please, describe how this Treatment(s) affected your Physical and Emotional Health: 

5. Please, clarify and describe if you have (had) any particular Excretory Complains or/and Problems (liver, kidneys, bladder, Gallbladder). Do you have Gall- or Kidney- Stones , Hepatitis, HIV, Cancer or any type of the inner inflammatory problems? Please, describe your Symptoms in details: 

6. Please, clarify and describe if you have (had) any particular Respiratory Complains or/and Problems (Sinus, Drip, Inner ear, Bronchial tubes, Lungs, etc.) Do you have Asthma, Tuberculosis, Bronchitis, respiratory Allergy, Sinusitis, Laryngitis, Inner ear infection, Cancer, etc. Do you have any complains regarding Coughing (dry or with extensive mucus, more extensive at the morning, evening or the night) , Sneezing, nasal or sinus pain and tension, low hearing? Please describe your Symptoms in details:

7. Please, clarify and describe if you have (had) any Digestive Complains or/and Problems (Gums, Teeth, stomach, Pancreas, Bowels, etc.). Do you have bleeding Gums, problems with Teeth (specify), Stomach pain or internal bleedings, Diabetes or Hypoglycemia, irritable Bowels, Gas, Heartburn, Colic, Constipation, Hemorrhoid, Overweight, Obesity, lack of appetite, serious Poisons, etc.? Please describe your Symptoms in details: 

8. Please, clarify and describe if you have (had) any Circulatory Complains or/and Problems (Varicose veins, Spider veins, High or Low Blood Pressure, Cerebral vascular problems, Heart attack, Stroke, Heart transplantation, Atherosclerosis, etc . Do you have (had) irregular Pulse (before of after an exercise), Extra systolic, Congestion, difficulties to breath and pressure in the heart area (regularly, before or after an exercise), cold feet and hands, easy nasal bleedings, easy bruises, dizziness, etc.? Please, describe your Symptoms in details: 

9. For Female Only. Please, clarify and describe if you have (had) any reproductive Complains or/and Problems (any particular genitals dysfunction, Fibroids, Cancer, PMS, Frigidity, Leucorrhea, etc.). Do you have Periods irregularity, intensive bleeding, Clots, painful breasts, PMS depression, Spotting, sleep problems and over irritation during the Period, any infection of reproductive organs, any inner inflammations or Pain, etc.? Are you on the Hormone Replacement Therapy (HRP)? Please describe your Symptoms in details:

10. For Male Only. Please, clarify and describe if you have (had) any reproductive complains or/and Problems (Prostate Cancer, any genital infections, Testicle or Prostate inflammation, etc.). Do you have (had) regular or irregular urination, any particular surgery? Please, describe: 

11. Please, clarify and describe if you have (had) any Nerve Complains or/and Problems: Migraine, frequent Headaches, Sciatica, Nervousness, Attention deficit disorder, Hyperactivity, Anxiety, Depression, Back Pain, Tremor, Alzheimer's or Parkinson's Disease, Epilepsy, any Psychotic reactions, Suicidal tendencies, Sleep problems, Very high Stress Level, Night mares, Multiple Sclerosis, infectious Meningitis, etc. Please, describe your Symptoms in details: 

12. Please, clarify and describe if you have (had) any Skin Complains or/and Problems: Acne, Eczema, Dermatitis, Psoriasis, Herpes, Hives, Rash, Warts, Skin Allergy, Burns, Skin Eruptions, Phlebitis, Skin Redness, Very dry Skin, Skin Cracking, Nipples Cracking, Fungus Infection, Keloids, etc. Do you have (had) Itchy Skin, Skin pain and/or Inflammation. In what places or areas of the Body? Please describe your Symptoms in Details:

13. Please, specify, if you have Arthritis, Rheumatoid Arthritis, Bone Cancer, Bone Tuberculosis, Bone transplants, Hair Loss (Baldness, Alopecia, Fungus infection, Dandruff), Nails problems, Tooth problems, Silver fillings, Injury, etc. :

14. Please, specify if you have any Muscular Complains or/and Problems: Muscular pain, muscular stretching, Paralysis, etc. Describe your Symptoms:

15. Please, describe your personal temperament using the appropriate following key phrases: Impulsive, Irritable, easy angered, angry when contradicted, prone to contradict, changeable and inconsistent, jealous, suspicious, critical, ambitious, egotistical, pessimistic, anxious and indecisive, lack of confidence, tend to theorize, conscientious about trivial matters, concerned with precision/accuracy, fastidious, anxious in company, tend to worry about everything, passive, think rapidly, think slowly, vain, dislike being touched, anxious about own health, talkative and frequently change subject, Low sex drive, affectionate, anxious about own health, sympathetic, like sympathy, dislike sympathy, moved to tears by music, cry readily, cry from anxiety, optimistic, hyperactive, have lack of attention, can not concentrate easy, like permanent motion, like rest and loneliness, like big company, like intellectual talk, like to share time with your kids, easy irritated by kid's:

16. Please, describe your Food preferences using the appropriate following key phrases: like warm food and drinks, dislike warm food, like raw foods, loss appetite during menstruation, like eggs (boiled), dislike eggs, like fruits , dislike fruits, like starchy food, like bananas, dislike to mix of foods, eat to bursting point, like ice cream, like fatty food, like bread and butter, like sweet foods, dislike sweet foods, like cheese, like olive oil, like salty foods, dislike salty foods, like oysters, dislike fish, like lemons, like pickles, dislike tomatoes, like spicy foods, dislike garlic, like garlic , dislike onions, like or dislike milk an diary products, like alcohol, little thirst, like or dislike coffee, like or dislike hot drinks: 

17. Please, describe if you have any of following Fears: heights, enclosed spaces, public places, mice, snakes, water, thunderstorms, sharp needles, ghosts, darkness, being alone, being late, being hurt emotionally, be poisoned by bad food or pollution, illness, insanity, cancer, death, for the health of your family, failure in business, poverty, loss of self-control:

18.Do your Physical Complains and Health Ailments are worse: in cold or warm dry, windy or wet weather? Are you sensitive to any smell or noise? During what time of the day you usually feel better and worse? 

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Thank you for the Patience and true detailed Answers! This information, is absolutely Confidential and very important for the your future Therapeutic treatment.