Health Questionnaire

All new patients must complete the following Patient Questionnaire before their 1st appointment.
Please either complete online using the form below
or download and return by clicking on the following button at the bottom of this page to me by email.

Patient Questionnaire

PERSONAL INFO
BASIC INFO
MEDICAL HISTORY
FOOD/DRINK
GENERAL
SLEEP
YOUER FAMILY HISTORY
CONSENT TO HOMEOPATHIC TREATMENT

First Name

Last Name

Date of Birth

Address

Address Line

City

State

Zip Code

Country

Phone/Mobile

Home Phone

ALL INFORMATION GIVEN HERE IS KEPT STRICTLY CONFIDENTIAL

PRIMARY REASON FOR SEEKING TREATMENT

When did it start?

Any factors that may have contributed to the onset of the condition?

What makes it better that you are aware of?

What makes it worse that you are aware of?

Is there a time in the day when it is worse?

Are there any activities that affect it?

Any other symptoms at all, even unrelated?

MEDICAL HISTORY

Think about any patterns of headaches, digestive problems, asthma, skin conditions etc.

Birth weight (if known)

Any reactions to vaccinations or any medical drugs?

Any known allergies?

Any injuries?

All other medical conditions

Any cold sores?

Any warts?

Any mouth ulcers?

Please list all current medication, vitamins and other supplements you are taking

Please give details of other therapies you are currently using

Please list ALL vaccinations you have had, date and any severe reactions

Please list all allergies and intolerances you have / had

Please list, in order if possible, any childhood illnesses, major disease, accidents, hospitalisation etc.

Please list, in order if possible, any life traumas you have experienced, e.g. bereavements

FOOD/DRINK

What are your life long favourite foods?

Favourite meat?

Do you prefer meat to fish?

Any foods or flavours you dislike?

Any foods of flavours you like?:

Are you thirsty?

What do you drink?

GENERAL

Any alcohol?

Any smoking?

Are you more likely to get too hot or too cold?

Do you perspire much?

Where from?

What is your best time of day?

What is your worst time of day?

SLEEP

Please describe your sleep pattern?

Do you have any problems with sleep?

Do you

Snore?

Talk?

Walk?

Grind your teeth?

How do you lie in your sleep?

Your Family History

Information about the health of your blood relatives, whether they are
still alive or have died, is of value to a Homeopath. Please give details about any serious diseases, history of alcohol and/or drug addiction, epilepsy, Down’s syndrome, behavioural problems, or any other unusual conditions or problems. Please give cause of death and the age of your relative, if known.

Your mother's side of the family

Mother

Grandmother

Grandfather

Aunts

Uncles

Your father's side of the family

Father

Grandmother

Grandfather

Aunts

Uncles

Sisters

Brothers

Children

CONSENT TO HOMEOPATHIC TREATMENT

I confirm that I consent to Homeopathic treatment from Cathy Tennant

Signed (Name)

Todays Date

Download Patient Questionnaire