Intake form · homeopathy, adults

Personal details

Full name

Email address

Personal information

Age

Date of birth

Do you have any diagnosis, medical or psychological condition?

If yes, what diagnosis?

Reason for the consultation, and history

What are the symptoms or problems you are seeking a homeopathic consultation for? (Describe the symptoms in detail, when and how they appear, and anything that influences them.)

When did the symptoms begin? Do they connect with any particular event or period?

What other health problems do you have? Your history of illness, in as much detail as possible. You can attach medical documents if needed.

What health problems do the parents, siblings or other blood relatives have?

What is the atmosphere like at work or in your place of study, if applicable? Have there been conflicts or other unusually demanding situations?

How is your relationship with your family (parents, siblings, partner, children, if applicable)? What is the atmosphere at home, and have there been conflicts or other demanding situations?

Weight, height, hair and eye colour

For women: what are your periods like? Frequency, length, anything particular about the flow, how you feel during them, and the age of your first period.

How are you right now, today: symptoms, sensations, anything particular, any detail?

Anything else you consider relevant

Do you have depression, or have you been diagnosed with depression?

On a scale from 1 to 10, where 1 is the mildest depression and 10 the worst you can imagine, which number would you say it is?

Do you have anxiety, or have you been diagnosed with anxiety?

On a scale from 1 to 10, where 1 is the mildest anxiety and 10 the worst you can imagine, which number would you say it is?

What makes you anxious?

Do you have fears? If yes, what are they?

Do you feel anger or rage? If yes, what makes you angry?

On a scale from 1 to 10, where 1 is the mildest anger and 10 the strongest you can imagine, which number would you say it reaches?

How well do you sleep at night?

How many hours a night do you sleep at the moment, on average?

Do you usually fall asleep easily, or not?

Do you usually wake during the night?

How many times?

Lately, would you say you sleep deeply, moderately, or very lightly?

What are your dreams like? Would you say they are usually pleasant, or unpleasant, with fears or even nightmares?

Have you ever had, or do you have, sleepwalking?

Have you ever had sleep paralysis?

Would you say you usually wake up rested and energetic, or still rather tired?

What would you say about the way you eat? Are there foods you prefer, and foods you never eat at all?

Are you taking any medication?

If yes, which ones and what for?

Have you had traumatic experiences in your life? If yes, please list the kind of trauma (physical, emotional, sexual, and so on).

Preference for warmth or cool, for being alone or in company

What are the bowel movements like (consistency, colour, frequency, associated sensations, anything else particular)

Taste preferences: salty, sour, sweet, bitter. Any other eating habits, particular cravings or aversions. Thirst, and how much you drink at a time and over 24 hours.

Details about the pregnancy and your birth (as far as you know or have been told): whether anything particular happened, the breastfeeding period, teething, the closing of the fontanelle, the age of the first unsupported steps, and the age of first words.