Classical Homeopathy Questionnaire

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Email Address

Date

DOB:

Height:

Weight:

1.What is your Chief Complaint (CC)?

2.When did this problem begin?

3.What aggravates the CC (certain types of food or weather, movement, light, noise, heat/cold, or anything else you can think of)?

4.At what time of the day or night is the CC the worst? Specify an hour if you can.

5.What symptoms can you identify that accompany the CC?

General Questions

Questions about the weather and environment: you need only answer those which apply to you.

6.In which season does the weather bother you most?

7.How do you react to cold, hot, dry or windy weather? Please mention any and all types of weather that affect you and how they affect you.

8.How does a change of weather affect you?

9.How do you feel in bright sunlight? Do you wear sunglasses a lot?

10.Do you have any special reaction before, during or after a storm? Please specify.

11.How do you react to drafts of air (ex: open window, having a fan on you)? Do you like to sleep with the window open even when it’s cold out?

12.How do you react to sudden changes in temperature (ex: going from cold environment to a hot room or vice versa)?

13.What about warmth in general; warmth of the bed, of the room, of the heater or stove?

14.How do you feel at the seashore, or on a high mountain?

15.What position do you dislike the most? Sitting, standing, lying?

16.Do you perspire a great deal? If so, when and where on the body (feet, head, hair, underarms, etc.)

17.What time of day tends to worse for you?

MENTAL/EMOTIONAL

18.What do you worry about? How do you deal with worries?

19.Do you tend to be neater and more fastidious than those around you, or more casual?

20.Do you cry easily? In what situations?

21.When you are upset, do you tend to tell a lot of people or keep it to yourself?

22.On what occasions do you feel despair?

23.In what circumstances do you feel jealous?

24.When and on what occasions do you feel frightened or anxious? Any fears (darkness, being alone, in crowds, altitude, flying, elevators, etc.)?

25.What are the greatest griefs that you have gone through in your life? How did you react?

26.What are the greatest joys you have had in your life?

27.In what situations do you feel the blues, depressed, sad, pessimistic?

28.What bothers you most in other people? How, if at all, do you express it?

29.Do you have a lack of self-confidence and a poor sense of self-worth?

30.What do you dream about? Do you have recurring dreams?

31.Do you consider yourself psychic or intuitive?

32.What would you need to feel happy?

33.What do you do for work? Ideally, what would you like to do?

34.If you had an unexpected week’s vacation from work and $1,000, what would you do?

35.How do other people view you?

36.If you could change one thing in your life, what would it be?

FOOD

37.How do you feel before, during and after meals? How do you feel if you go without a meal?

38.What would you most like to eat (if you did not have to consider calories, fat, anything you’ve read about the right way to eat)?

39.What foods do you dislike and refuse to eat? What foods do you react badly to and in what way?

40.How much do you drink in a day? Include sodas, juice, coffee, milk, and alcoholic beverages as well as water. How thirsty do you get?

SLEEP

41.What hours do you sleep? Do you tend to wake up at a particular time? Why? What makes you restless or sleepy?

42.Do you do anything during sleep (speak, laugh, shriek, toss about, grind your teeth, snore)?

43.How do you feel in the morning?

HEALTH HISTORY

44.What medications or supplements are you taking at present?

45.Any issues with bowel movements? (diarrhea, constipation, etc.)

46.How frequently do you get colds and flus?

47.Have you had any childhood illnesses twice, or in a very severe form, or after puberty?

48.Have you had vaccinations since the standard childhood ones? Have you ever had an adverse reaction or unusual reaction to vaccinations?

49.Have you had any surgery? What and when?

50.Have you had at any time (mention year): What therapy was given?

a)Warts? Where? When? How treated?

b)Cysts? Where? When? How treated?

c)Polyps? Where? When? How treated?

d)Tumors? Where? When? How treated?

e)Skin disorders? Where? When? How treated?

51.Do you tend to need a smaller dose of medication than most other people?

FAMILY HISTORY

52.Family History: Mention diseases, causes and ages of death of parents, siblings and grandparents on both sides.

53.CONSTRUCT A TIMELINE: Mention from birth to the present day all important events (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 or of friends, disappointments, etc.). Mention the symptoms experienced at those moments or which you can date to those traumas. Please try to write at least one page outlining major events of your life.

54.What else would you like to tell me about yourself or your condition?