Your Online Homeopathic Consultation
with Denise Clark PHSH RSHom
This questionnaire will enable appropriate and effective
homeopathic treatment online.
This online consultation service is best for non-acute, (non urgent)
matters which are long term, (chronic) disturbance to your health,
whether emotional. Intellectual or physical.
Many of you feel more at ease discussing potentially embarrassing
health issues by email rather than a face to face environment.
Note: All consultations and answers to questions are held in the
This questionnaire is available for completion online at http://
Please answer the following questions in as much detail as you
possibly can then email your completed questionnaire to:
Once you have completed your questionnaire please arrange
payment. The fees are UK £80 for a first consultation UK £40 for
a follow up consultation - usually needed about 4 weeks later
depending on the problem.
These fees cover a short follow up at 5 days after taking your
remedy and any urgent short questions which arise from time to
time, these will be by e-mail or phone (pre-arranged phone time, for
5 day follow up).
You may pay via www.paypal.com
using my ID firstname.lastname@example.org
Contact Details E-mail email@example.com
Telephone / from UK: 07980 541 552 Telephone / outside UK:
(+44) 07980 541 552
If you would like to contact me via post then please send all
The Castle Street Clinic 19 Castle Street, High Wycombe, Bucks
These questions will help jog your memory and enable you to show
me what I need to understand about you. Please just type your
answers after each question, thank you.
1. Personal Details
could you please supply some personal details about yourself. I do
not require all the information listed below initially, but do need your
name and a valid e-mail address before we can proceed. It may be
a good idea to read this questionnaire through before filling it
in. there may seem to be questions that ask the same things,
please consider them carefully, it is time well spent.
Zip or Post Code:
Age & Date of birth:
Gender: Marital Status & No. Of Children (if any):
Height, Weight & Physical Description, including colour of hair and
Are you working and if so what do you do?:
Hobbies, what do you enjoy doing?:
2. Reason for Visit
Imagine you are with me in my consultation room, tell me what has
brought you here today? What symptoms bother you most of all?
Be as specific as you can.
I like to let my patients talk and tell me as much as they can about
their symptoms. How do you feel about your symptoms, and how do
you see homeopathy helping? Just type or write away as much as
you like. You could answer the following questions and come back
to this question later.
3. Why have you chosen now to have this consultation?
This is important, your reason for acting now will help me find your
most suitable first remedy. Why have you chosen homeopathy?
4. Current Symptoms
Please try and describe all the current symptoms in your own words
including if possible, the cause of each symptom , when they
started if your remember that. A help here is remembering what was
happening in your life when each symptom started. If you have
more than one present symptom please state the details for each
Please give the exact area of your body if your symptoms are
physical. If your symptom is emotional, does it cause a physical
sensation in you while it's happening?
Are you aware of what may have helped cause them?
Have you had these symptoms in the past also?
Is there anything about these symptoms you think could be
absolutely unique to you, anything you or others might think odd
Again this is very important for finding your remedy, anything
unusual is like a key.
5. General Symptoms
This is how you are generally affected by outside influences etc.
How you work as a whole. I am interested in what makes you tick
and how you tick in general. What makes you better or worse.
Which weather do you feel less well in?
Does fog affect you, if so how?
Is there a time during the day or night that your symptom/s feels
worse, if so how is it feeling?
How do you like the cold/hot/dry/wet weather?
How do you feel when exposed to the sun?
Do changes of weather affect you at all?
What are your reactions to the wind in general?
Do you feel anything before, during and after a storm?
How are you for warmth in general, warm bed, room, central
Do draughts and changes of temperature bother you?
Can you tolerate extremes in temperature, if so how well?
How much extra clothing in winter do you wear, e.g. how many
Have you observed any position you seem to like being in (e.g.
Do you tend to getting colds in winter and in other seasons?
Could you stand or kneel for long periods?
Is there a climate that you hate, and where would your ideal
Do you like your bedroom windows open or closed at night?
Do you play sports?
Any problems with riding in cars or sailing?
How do you feel before / during / after meals?
What’s your appetite like?
How do you feel if you go without a meal?
What do you drink and in what quantity? Are you thirsty?
Are there foods that make you ill and why?
How are you with wine / beer / coffee / tea / milk / vinegar?
Do you smoke, if so how much do you smoke in a day? How do you
feel after smoking?
Any drugs which you are very sensitive too or which make you ill, if
so ill in what way?
Have you had vaccinations, if so have you had any kind of reactions
Do you like cold or warm baths, or sea bathing, swimming pools?
Any change in the way you feel at the seaside or on high
Do collars, belts and tight clothing affect you?
How long do your wounds take to heal and how long do they bleed
Any circumstances make you feel like fainting?
Mental and Emotional Symptoms Your frame of mind while you
are feeling unwell are extremely important in indicating remedies
for you, try to give all these symptoms careful consideration before
What is your greatest sadness in your life now?
What grief do you remember from your past?
What are your greatest joys in your life now?
What about joys you remember from your past?
Do you ever feel jealous? If so in what circumstances?
Do you weep? If so on what occasions, at music? at reproaches? at
what time of day, or any other incident? (You could give an incident
here that springs to your mind)
How do you cope with your worries, how do you react? What would
cause you to worry?
What effect does consolation have on you? (do you like it or not?
are you indifferent maybe?).
Have you ever felt despair, if so when?
Does having to wait for anything or standing in a queue bother you?
Would you ever feel frightened or anxious at anything or in any
Do you mind being in a room full of people?
Do you get angry ever? If so what do you do if you get angry? What
makes you angry?
Does your face colour red or pale when you are angry?
How do you feel after getting angry?
Would you say you walk or eat or talk or write rapidly or slowly?
How are you effected following chagrin, grief, disappointed, love,
vexation, mortification, indignation, bad news, fright?
Would you say you are over-conscientious or over careful about
anything or even small things ? (some of us don’t care about details
and some of us care a great deal).
How is your memory? (What would you forget? Give details
Your understanding? (How do you comprehend and process
information, either spoken or written)?
Your will? (is it strong etc.)?
Your concentration? (e.g. does your mind wander)?
Any tendency to make mistakes? (in writing or speaking or any
If you ever feel depressed, sad, pessimistic? If so is there a
particular time in a twenty-four hours period would you feel any of
these emotions or if other give details please?
How do you feel about death?
7. Food and Sleep
I need to know as much as possible about your sleeping and eating
habits as these are important aspects of you. The food you crave or
particularly enjoy could show those nutrients, vitamins, minerals etc
you may be lacking in or find it hard to absorb.
What are the foods you have a marked craving for or hated of?
What kind of foods would make you ill or are you are unable to eat?
How are you with pastry and sweets?
How about sour or spicy food?
How about rich or greasy food?
How’s your thirst (how much would you drink daily)? and what do
you like to drink?
Do you add extra salt to your food, if so how much?
Is there anything you don’t drink, such as coffee or tea, if so why
don’t you drink those?
What position do you like to sleep in? How long have you slept in
that position for (e.g. is it since an ailment or for as long as you can
Where do you put your arms, and how do you like to have your
head, what kind of pillow and bed do you like?
What time do you wake up and how do you feel on waking?
Are you sleepy at any particular time of day or evening?
Does anything make you restless or sleepy?
Do you have any recurring dreams, if so how do they affect you,
make you feel during the dream? Do you remember you dreams
Have you been observed talking, singing, laughing, crying out,
weeping, walking or any other during sleep? Are you restless,
afraid, grinding your teeth? Do you have your mouth open? Do
you have your eyes open?
8. For Women Only
These questions may appear overly inquisitive. Your answers help
me understand what’s going on for you. I feel women don’t need to
have pain connected to their menstrual cycle or when going through
What age were you when your periods started?
At what frequently do your periods come, how many days apart?
Please describe their duration, abundance, colour, odour, any
changes in these as your period progresses?
Are there any other significant details that may be relevant?
At what time in the twenty-four hours do they flow most?
How do you feel before, during and after your period emotionally,
(please be specific as possible here, how do you feel and behave)?
9. Bodily Functions and Discharges
Here I need the sensations, the locations, what modifies them and
any accompaniments to them. Skin 9a. Any skin symptoms need to
be described in great detail as I cannot see them and they are of
great importance. You can send me a photo if you wish, that would
be most useful.
Do you have any skin problems like eczema, warts, tumours,
psoriasis or unexplained eruptions?
Are they dry, moist, oozing, and what are they oozing, what is the
nature of the discharge, what colour is it, does it smell?
Where on your body did they start, and in which part of your body
are they now?
And when did they start, was it after a vaccination or any other
medication? after a grief, anger, mortification or any other emotion?
Do they come and go, if so when (times of year, different weather)?
Do you use any creams etc on your skin or eruptions, if so which
Do you have any problems of your senses, hearing, vision, smell or
Do you have any problems in your mouth or dental problems?
Has a diagnosis been made for any condition you have? If so by
whom, and what is it? Please detail any advice given on these
Are you taking any homeopathic remedy, conventional medication,
herb, vitamin or mineral supplement?
Do you follow a special diet?
Do you take any exercise, if so what do you do?
In case you did not mention it above, do you feel any pain or
Is the pain you feel burning, aching, numbness and/or throbbing or
If you do have pain what helps it feel better and what makes it
aggravate? (I’m not referring to any painkillers here only other
things you can do to help pain, like heat, cold, position etc.). Please
give any other information, e.g. do you take painkillers?
What does your tongue look like? Changes may be seen in your
tongue after taking your homeopathic remedy so you need to be
aware of how it’s looking now and be on the alert for any changes.
Please complete the sentence, 'It feels as if .......' about all your
pains or discomforts. (This can be an emotion of something
happening or physical of something happening or any other you
wish to use as your description).
Often family members observation’s of there loved ones can be
very helpful, If you feel this to be so then ask any relevant others to
e-mail me with there comments.
10. Your Personal History
Please detail you medical history since childhood as far as you can
recall, including vaccinations, childhood and travel, accidents, time
in hospital etc. ( If you can, list these in the order of appearance and
occurrence). Have you ever been inclined to ‘get’ certain things over
and over again?
Were your childhood milestones in development early or late (first
cutting teeth, first walking, first talking).
Please provide as much information as you can about the medical
history of your immediate family and grandparents. (e.g. family
tendencies, e.g. Rheumatism, blood pressure, asthma, allergy,
piles, diabetes, cancer, mental disturbance etc.).
Can you tell me about your home life and any important
What are you particularly interested in, what do you do with your
Never been well since. Are there any incidences that have
occurred e.g. physical – injury, exposure to damp, cold). Emotional
(grief, disappointment, stress etc.) disease/ill health or taking
medication or drugs. Have you noticed not feeling well since any or
a combination of these situations listed, or any other situation?
Are their any important aspects of your life that have not been
covered here? If so please add as much as you can.
What do you want homeopathy to help you with most of all?
Thank you for completing your questionnaire. I will contact you to
acknowledge I have received it as soon as you send it to me.