New Patient QuestionnairePlease fill in as much as you can to the questions, and return prior to the consultation. Open Form New Patient Name First Name Last Name Date of birth Phone (###) ### #### Email Address DESCRIBE BRIEFLY YOUR MAIN REASON(S) FOR CONSULTING A HOMOEOPATH: LIST ANY MEDICATION THAT YOU ARE CURRENTLY TAKING ( INCLUDING THE CONTRACEPTION PILL, VITAMINS AND FOOD SUPPLEMENTS) GIVE DETAILS OF ANYTHING THAT YOU ARE ALLERGIC TO - FOODS, DRUGS, ANIMALS ETC.: FAMILY HEALTH HISTORY. Please give details of the health history of your relatives. For example: Diabetes, heart disease, cancer, tuberculosis, thyroid, mental disease, suicide, alcoholism, etc. INCLUDE FATHER, MOTHER, GRANDPARENTS, SIBLING, UNCLE, AUNTS: PERSONAL HEALTH HISTORY Please fill in this section giving as much information as possible including dates. Remember to mention your approximate age at the time of any health problems. INFECTIOUS CHILDHOOD DISEASES: (Measles, mumps, chicken pox, whooping cough, glandular fever etc. / State if mild or severe): PERSONAL HEALTH HISTORY Please fill in this section giving as much information as possible including dates. Remember to mention your approximate age at the time of any health problems. INJURIES AND ACCIDENT OPERATIONS AND SURGICAL PROCEDURES SKIN: Warts, verrucae, herpes (cold sores), abscesses, boils, moles, eczema, impetigo etc. WEATHER & ENVIRONMENT REACTION: (What weather suits you best? Do you feel the cold/heat/wind/drafts/damp/humidity? Do you prefer warm rooms or desire fresh air etc.?) APPETITE & THIRST: (What foods/drinks/flavours/condiments etc. do you either crave or have a strong dislike of? Does any food or drink cause an adverse reaction? How thirsty are you?) FEARS OR PHOBIAS: (For example - heights, closed spaces, dark, germs, ghosts, animals, insects, snakes, spiders, storms, examinations, disease, poverty, failure etc.) DREAMS : (Any dreams that stay in your memory. Any recurring dreams. Include childhood dreams. Please try to recall at least one dream that you have had in your life.) ANY OTHER HEALTH PROBLEMS INCLUDING LIFE TRAUMAS, GRIEFS, SHOCKS ETC Thank you!
