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About Me
Homeopathy
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Adult Questionnaire
OUR Adults questionnaire Form Adults
Adult Questionnaire
Adults questionnaire Form Adults
First Name
Surname
Gender
Male
Female
Skype Name
Email
Mobile Number
Date Of Birth
Age
Street Address
Street Address Line 2
City
Postal / Zip Code
Chief Complaint (Medical Condition)
If possible, mention vaccinations received:
Any adverse reactions?
Please describe childhood diseases, if it happened twice or in a very severe form, or after puberty?
How frequently do you get cold and flus?
Very often
Often
Seldomly
Rare
Very rare
What medications are you taking at present?
Any surgeries?
Please mention the presence of the following
Polyps
Cysts
Warts
Figworts
[Other ]
Do you tend to have any discharges:
Nasal
Urethral
From the Ears
Type option 4
Other
Please describe colour and consistency
Does it have any particular smell?
Do you react bad to anesthesia or had a hard time to come out of it (e.g. headaches, vertigo, nausea, vomiting)?
Do you tend to react badly to medication
Yes
No
Are you sensitive to paint, perfumes, exhaust, fragrances, etc?
Yes
No
Which season bothers you the most?
Autumn
Winter
Spring
Summer
How do you feel in bright sun light?
How do you feel in drafts?
Any reactions before or after a storm?
Do you like to sleep with the window open?
Yes
No
Sometimes
How do you feel at seashore or high in the mountains, please specify preference?
How do you feel before and after meals?
What happens if you skip a meal?
What are your favorite foods (please disregard any idea of what is healthy or not, I need to know what you truly like, even if it is the fat of the bacon!)?
What food do you dislike or refuse to eat?
Please state foods that you like but react badly and in what way?:
Do you like salt?
How much do you drink in a day?
Comparing with other people around you, how thirsty do you tend to get?
Do you prefer water from the fridge or at room temperature?
From the fridge
Room temperature
Both
How many hours do you sleep? Please include bed time and waking up time.
Do you tend to wake up in the middle of the night? And at what time?
Do you do anything during sleep (laugh, speak, snoring, grinding the teeth, toss about)?
How do you feel in the morning immediately after waking?
In which position do you tend to sleep (sides, back or abdomen)?
Side
Back
Abdomen
If on the sides, do you have a favorite one?
Do you have recurring dreams
Yes
No
Is there a main theme?
Do you perspire a lot? When and where in the body?
What Position you dislike the most, lying, standing, sitting:
What Time of the Day tends to be a down time for you?
Skin (eruptions, itchiness):
Bowels regularity:
What do you worry about?
How do you deal with worries?
Are you more fastidious or neater than those around you?
Do you cry easily?
Yes
No
In what situations?
When you are upset, which of the following do you do?
Tell to a lot of people
Keep it to yourself
On what occasions do you feel despair?
In what circumstances do you feel jealous?
In what circumstances do you feel frightened ?
What where the major grieves you had in your life?
What are the greatest joys you’ve had in your life?
In what situations you feel sad, depressed, pessimistic?
What bothers you most in other people and How do you express it?
Which of the following do you have?
Lack of confidence
Poor sense of self-worth
Both
What would you need to feel happy?
Ideally what would you like to do for a living?
How do other people view you?
What are your favorite hobbies?
What would you like to change mostly about yourself?
Is there anything else you would like to tell me?
Mother
Father
Siblings
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Please try to construct a time line with major grieves/traumas that happened in your life (events that marked you or had an impact in your life in chronological order, example below) :
2 years old - Kinder garden trauma followed by bronchitis
5 years old - Moving from a flat to a bigger house
9 years old - Older sibling left home
11 years old - Screaming fights between parents
12 years old - Hay Fever
22 years old - Relationship trauma
39 years old - Death of a friend
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