Questionnaire for patients

Hello!

Please fill in this form and send it to me. I will get in contact via email with instructions of remedies and how to take them.

I may ask you some further questions if necessary.

All fields are required, so write "none" rather than leave it blank.

The information provided is strictly confidential.

ACUTE QUESTIONNAIRE

* Indicates required field

Name *

Age *

Address *

Mobile *

Postcode *

email *

Occupation *

Fill in the questionnaire the best that you can giving as much detail as possible.

When did this problem start? *

Describe the problem that you need help with or complaints in your own words; in other words, tell what happened, including whether the acute came on suddenly or gradually. *

Describe the pain or other sensation you have. Does it extend anywhere, does it shoot anywhere? For instance, “It feels like there’s a lump in my throat, I’m constantly trying to swallow. The pain shoots to my left ear.” *

What caused you to get sick or develop the problem? Think about what was going on at, or around, the time of the occurrence. The answer may be obvious if you were stung by a bee or fell out of a tree; but, less obvious things would include things like: change of weather, suppressing feelings or suppressing symptoms with drugs, over-studying, receiving good news or bad news, having to put up with rudeness, loss of vital fluids–from diarrhea, bleeding, excessive sex, etc.; loss of a loved one, loss of property, jealousy, fright, use of drugs–prescription or otherwise– never recovering completely from an infection like the flu or other illness, suppressing a fever with anti-fever medication, loss of sleep, surgery, too much alcohol, too much junk food, getting the feet wet, going out in cold dry weather, drinking cold water on a hot day, embarrassment, breathing in dust, over-exertion, exposure to toxins, vaccinations, etc. *

Appearance– what does it look like? Red skin, puffy, bruised, etc.? Send a picture via email if necessary. *

Location–where on the body is your complaint located? *

“What makes your complaint better or worse”? Please don’t say “nothing!”, THINK! This question is important. Consider the following possibilities: Better or worse from hot or cold applications, weather, bathing/showering, warm rooms, fresh air, drafts, motion, sleep, a certain time of day, massage, hard pressure, assuming a certain position; stimuli (conversation, noise, talking, light, touch, rubbing, music, company, consolation, sympathy, etc.), eating, drinking, ice, hot tea, milk, sweets, chocolate, etc. Remember, these are only examples. Think about your case: what makes you feel somewhat better? What makes you feel worse? *

Discharges–color, odor, consistency ( thick or thing, stringy, etc) and sensation. *

Which other symptoms that came with the complaint –Another way of asking this is, “What ELSE is going on at the same time?” It could be anything: fatigue, ringing in the ears, back ache, burping, salivation, dizziness, sneezing, anxiety…it could be important or unimportant. For example: Headache with irritability, headache with runny eyes, menstrual cramps with vomiting, diarrhea with chills or vomiting, etc. *

Does it affect only a particular side, left or right? or is it worse in only one side? *

Are there any homeopathic remedies or protocols that you have taken already? Have any of those remedies been helpful? Please state remedies potencies, how often this remedies were taken and for how long *

The mentals: Is the complaint changing you mentally and emotionally? Think about: irritability, panic, anxiety, weepiness, self-pity, confusion, crying, dullness, apathy/indifference, overly cheerful, optimistic, pessimistic, and so on. *

What are you doing? For example, tossing and turning, pacing, arguing, fidgeting, moaning and groaning, calling people on the phone for support, just lying down and not caring, sleeping excessively, doing anything excessively or not enough, etc. *

Fever? Can you describe it? For instance, is it constant, or does it come and go? Is it a dry fever or accompanied by perspiration? Anything else you can say about it, like, goes away outside, worse in warm rooms, worse in hot bath, comes on every day at 5 o’clock, etc.? *

If you have a cough, please tell what it sounds like; for example, “It’s a dry cough that sounds like a saw sawing through a pine board!” or, “It sounds like a seal barking!” or, “It’s loose and rattling and yet, raising phlegm is very difficult.” or, “It’s dry, it’s a very sharp sound, and it’s very painful, it makes my head hurt, I have to grab my head.”. Also where is the cough coming from? Chest, throat? *

If you have a cough, it is productive? are you wheezing ? is your voice hoarse? *

Describe any allergies to dust, grass, polen, animals, food *

Describe your thirst and appetite–are you thirsty, not thirsty, what temperature do you want your drinks, what kind of drinks do you want, just sips, or gulps, frequently or infrequently? Are you craving certain foods or avoiding certain foods? Is there a food or drink you simply must have or you’d feel deprived? *

Sweating? Describe. When does the sweating occur? Where on the body? Any particular odor? Does it leave a stain of a particular color? *

Describe your energy–are you nervous, quiet, restless, agitated, sleepy, dull, prostrated, collapsed, stuporous, anguished, desperate, active, cheerful, energetic, bubbly, etc. *

If you haven’t already said if you’re hotter or colder than usual, or if there’s an issue with your body temperature, like hot feet or cold feet, cold hands, shivering, etc., say it now. *

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ACUTE QUESTIONNAIRE

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