Questionnaire for patients

Hello!

Please fill in this form and send it to me before your first appointment.

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

The information provided is strictly confidential.

FOR ONLINE APPOINTMENTS WITH SKIN PROBLEMS.
PLEASE SEND A COUPLE OF PICTURES WITH AN AREA OF THE SKIN AFFECTED. TRY TO GET A CLOSE UP AND A GENERAL ONE IF POSSIBLE.
Send your pictures to cristinahomeopathy@gmail.com

HEALTH QUESTIONNAIRE

* Indicates required field

Name of Patient *

Age *

Occupation *

Address *

Postcode *

Country *

email *

Briefly describe the condition for which you would like to consult me and an approximate date when the problem started. If you have a medical diagnosis for your condition please state here and if it was given to you by a medical doctor or naturopath. *

Family Health History-Please include Father, Mother, Grandparents, Brothers, Sisters and uncles For instance: diabetes, heart disease, cancer, Tuberculosis, thyroid, mental illness, alcoholism, arthritis, autoimmune disease, eczema, psoriasis, asthma, hay fever… *

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

Mention any homeopathic remedies or Banerji Protocols that you have taken ( including potency, frequency and for how long you have taken them) for your condition and describe if any of those have been helpful *

List any medications or supplements you are currently taking including the contraceptive pill or coil *

Have you ever suffered from any of these conditions? Please give details if you have. Abscesses, Anaemia, Arthritis, Asthma, Boils, Bronchitis, Cancer, Chicken Pox, Cold Sores, Diabetes, Eczema, Epilepsy, Frequent Colds, Fibroids, Gallstones, Genital Herpes, Herpes, Gonorrhoea, Gout, Heart Disease, Hepatitis, Influenza, Kidney Disease, Lyme Disease, Malaria, , Mononucleosis, Pelvic Inflammatory Disease, Pleurisy, Pneumonia, Prostatitis, Recurrent cystitis, Psoriasis, Rheumatic Fever, Reflux, Skin Diseases, Sinusitis, Strep Throat, Syphilis, Recurrent tonsillitis, Tuberculosis, Vitiligo, Venereal Warts, Warts, Whooping Cough, Worms. Any other not mentioned in here? *

Injuries and accidents including operations *

Have you or your family ever suffered from a big loss such as the death of a dear person, the loss of property, a job or a family break up? *

Please state all vaccinations received, dates that they were given and any problems or adverse reactions *

Can you trace the origin of any present condition to any particular circumstance? eg. emotional upset, accident, medications, grief.... *

Women only. Have you ever taken any form of contraceptive method, If so when? *

How often do you tend to get colds? Please be as specific as you can. For instance- once a year? every month? Never? *

Fevers- when was the last time you had a fever of 38.5 C /101.3 F or above? *

PLEASE EMAIL ME ANY MEDICAL REPORTS IF NECESSARY IN CASE OF DEEP SEATED DISEASE

send the form to cristina

HEALTH QUESTIONNAIRE

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