Online Questionnaire


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Online Questionnaire

  1. 1. 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 strictest confidence. Data Protection 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 using my ID Contact Details E-mail Telephone / from UK: 07980 541 552 Telephone / outside UK: (+44) 07980 541 552
  2. 2. If you would like to contact me via post then please send all correspondence to: The Castle Street Clinic 19 Castle Street, High Wycombe, Bucks HP13 6RU 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. First name(s): Surname: Address: Zip or Post Code: Country: Email: Telephone number: Age & Date of birth: Gender: Marital Status & No. Of Children (if any): Height, Weight & Physical Description, including colour of hair and eyes: 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
  3. 3. 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 one separately. 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 about them? 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?
  4. 4. 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 heating etc? 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 extra layers? Have you observed any position you seem to like being in (e.g. standing)? 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 vacation be? 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?
  5. 5. 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 from them? 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 mountains? Do collars, belts and tight clothing affect you? How long do your wounds take to heal and how long do they bleed for? 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 answering. 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?
  6. 6. 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 situations? 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 please). Your understanding? (How do you comprehend and process information, either spoken or written)?
  7. 7. 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 other)? 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. Food 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? Sleep
  8. 8. 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 remember)? 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 generally? 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 the menopause. 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. 9. 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 ones? Do you have any problems of your senses, hearing, vision, smell or taste? 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 conditions. 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?
  10. 10. In case you did not mention it above, do you feel any pain or discomfort? Is the pain you feel burning, aching, numbness and/or throbbing or other sensation.? 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.).
  11. 11. Can you tell me about your home life and any important relationships? What are you particularly interested in, what do you do with your leisure time? 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.