Questionnaire for Online Homoeopathic Consultation


This questionnaire is to help give me a clear picture of you as a person.

Please be frank and honest, whatever that means for you. By trying to ‘sanitise’ your complaints, you will not help me to find the appropriate treatment.

All details are completely confidential.
 

* Required fields
Name *
E-mail Address *
Address *
How long have you been in this area/country? *
Date of Birth *
Place of Birth *
Occupation
How long have you been in this occupation?
Please list the nature of your complaint/s that you have, in the order of importance to you. *
Can you remember how or when these problems started? If so, please give a description of the circumstances and events leading up to them. *
Please give a description of your energy during the day. Do you wake up tired, or get low spots through the day? If possible, tell me what time/s you experience this. *
Please describe your sleep patterns, giving times for going to bed and waking. List any preferred sleep positions, body temperature in bed, dreams, times wake during the night etc. *
Please tell me any food likes, dislikes, allergies or ailments after certain foods. At what time of day are you most hungry? *
Please list your drinks throughout the day, preferred drinks, whether you sip or gulp or drink normally, and your thirstiest time of the day. *
For women, please give details of your menstrual cycle - its regularity, duration, flow description. Any clots, pain, cramps, PMS, other symptoms associated with the period ie. headaches, constipation, tiredness, mood swings or libido change?
For women, please give details of any hormonal treatment (birth control, menopausal, egg donation, etc)
What is your body temperature - are you a hot or cold person? Do you wrap up, strip off or regulate with the changes in temperature? *
Emotionally how would you describe yourself at the moment? Happy, sad, anxious, depressed, contented? *
Please indicate if you have any emotional weaknesses with anyone - for example a relation, a friend, a work colleague.
Please describe in your own words how you were born (if known), your mother’s health through her pregnancy, delivery and if you were breast fed. Please list your history of illnesses starting from a child – physical, mental or emotional.
Please detail how the above illnesses were treated and if there were any problems with the treatments. *
Please include all serious ailments of blood relations as far back and sideways as you can go! Please include causes of death. *
Please detail anything that frightens you or makes you anxious.
Please indicate any vaccines you have had (childhood, travel, armed forces, etc) and any adverse reaction to them. *
Do you want a telephone or email consultation? *
Comments and Further Information

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NOW YOU HAVE FINISHED THE QUESTIONNAIRE

FEES:

The fee structure includes the supply and postage of the remedies to you, inside Australia. If you wish to obtain the remedies locally, please deduct $10 from the consultation fees, listed below.

Postage outside Australia may be charged extra.

Adult initial consultation: $100
Adult follow up consultation: $75
Child under ten consultation: $75
Animal consultation: $65

Currency is in Australian Dollars.

To pay for the consultation, please go to the Catalogue of Products.

Consultation will commence upon payment.

If you have indicated that you would like a telephone consultation, we need to book a mutually convenient time for you to ring me. I will email you on receipt of the questionnaire and funds.

Depending on the severity of your condition, depends on the recommended frequency of consultations. I will advise you at the time of consultation.

When your problems have been resolved, I advice a twice annual consultation, to retain optimum good health.

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