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Date Of Birth
Street Address Line 2
State / Province
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?
What medications are you taking at present?
Please mention the presence of the following
Do you tend to have any discharges:
From the Ears
Type option 4
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
Are you sensitive to paint, perfumes, exhaust, fragrances, etc?
Which season bothers you the most?
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?
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
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)?
If on the sides, do you have a favorite one?
Do you have recurring dreams
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):
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?
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
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?
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
© 2019 Alex Carneiro de Melo, PhD - Homeopath in London UK. All Rights Reserved