Ask a Homeopath . . .
   
 
The fee for a complete Work Up is $225. This includes Hair and Facial Analysis.  You must complete all questions below.  You will need to pay prior to submitting your completed questionnaire. Once you complete the payment section please return to this page to answer questions.  The Doctor will notify you via return e-mail when your analysis is complete. Please read the INSTRUCTIONS again to make sure you follow all directions.

 


Homeopathic Health Questionnaire

ALL FIELDS MUST BE COMPLETED

This form is NOT submitted via the internet!! You must print the form first and fill out in pen OR fill and out and go immediately to the print function of your browser.
Hitting enter will erase all your information.

What is your name:
Address:
City: State: Zip:
Telephone# Area Code
Fax# E-mail:
Date of Birth: Place of Birth:
Sex:Male  Female  
Marital Status:
Profession/Occupation:
Doctor:
Doctor's Telephone# Area Code
Doctor's address:
Doctor's Diagnosis:
For what problem(s) do you need my research? 
Vitamins/Supplements/Herbs you are now taking. List all and amount taken.
Prescribed  medication you are taking now and have taken in the past (all).
Have you EVER taken Homeopathic Remedies or Herbal products? 
List all and potency of remedy.
Height:   Weight: Blood Type:
Blood Pressure:  
If you know exact please list - if you do not know exact - list whether high or low.
Blood Sugar:  
If you know exact please list - if you do not know exact - list whether high or low.

LIST YOUR MAIN SYMPTOMS:

Present Complaints: List each complaint and describe in detail.



Onset Origin or Cause - When did most of these complaints begin?


Past History (Previous diseases and treatment) List details about your past medical history, including operations and injuries.
MIND SYMPTOMS - Check all that apply
Restless       Anxiety        Fear  
Depression  Melancholy Suicidal 
If suicidal, do you have a hard time keeping from it?  
Is suicide on your mind constantly?
Are you afraid of being left alone?
Do you think it is useless to take medicine?
Do you fear death?
Do you count pennies (Miserly)?
Are you courageous?
or lack courage?
Are you fearless? 
Are you resentful?
Are you hypersensitive?
Not sensitive at all?
Are you intuitive?
Have you moved residences a lot?
Why?
Memory -check all that apply.
good memory  bad memory do you get lost hallucinations
forgetful  
Handwriting check all that apply.
omits letters/words  dyslexia  calls by wrong name
General Attitude/Behavior check all that apply.
selfish  haughty abusive   curse     cruel  bites hits
complaining          Autism    obsessive/compulsive 
ADDS  Hyperactivity             Abuse   
Phobias - check all that you have experienced.
heights   bugs       riding in cars  women  
snakes   cats        elevators        children 
animals  dogs       people            colors
birds      crowds    men                 other
What other phobia?
List any Allergies you have:

Family History - Give in detail if any of your relatives are suffering or have suffered from the following:


ALLERGIES:(Check all that apply)

Eczema Skin Allergy  
Hay Fever Sinusitis or colds  
Allergic Bronchitis Asthma  
Urticaria  

ARTHRITIS: (Check all that apply)

Gout   Osteoarthritis
Rheumatoid Arthritis  

OTHER MEDICAL CONDITIONS: (Check all that apply)

Cancer/Malignancy Diabetes Mellitus
Hypertension Coronary Heart Disease
Tuberculosis Gonorrhea/Syphilis or STD
Psychiatric or Mental Disorders Schizophrenia
Anxiety Neurosis Depression  

Any other sickness not mentioned above?


PERSONAL HISTORY: Kindly elaborate and mention habits like alcohol, smoking, drugs tobacco etc.
Petroleum exposure:
Type Furnace you have
Sun Light problems
What happens:
Mother's Symptoms:
 
Father's Symptoms:
Brother's/Sister's:
Pets:
Head Symptoms - check all that are a problem for you.
Headaches  Location:

Migraines  When: 

Scalp itches   When

dandruff   sores   redness

Humid eruptions   scabs   pus   Pain   Redness   heat

Rash   Eryseplysis  Eruption  spot   location

Sensitive   Cannot brush hair   Burning

Hair loss   alopecia areata   ringworm

scalp dry   hair dry   tangled in bunches

scalp oily   hair greasy   forehead greasy

itching of scalp   margins of hair

worse after anger: 

cause of anger: 

Face Symptoms - check all that are a problem for you.

Bloated  Red  Swollen 

eruptions   location

Roseola  cancer  acne  location:

color: jaundice

pain  moles  warts  cysts

Nose Symptoms - check all that are a problem for you.

pain at root of   pointed end knobby end

Swollen  enlarges  fanning aleoi

eruption / wings  eruption  location

polypi   perforated septum   sinuses
Eye Symptoms - check all that are a problem for you.

Burning   Watering   Pupils   Vision   Glaucoma

Cataract   blindness   misty   blurred

upper lid   lower lid   growths

tarsal tumors   Blepharitis

Dry   rings around   bloated

prominent   small   sunken

Mouth Symptoms - describe as best as you can.

Tongue description

TeethAre teeth coated 

Color of coating Gums  

Throat Uvula

Dry   Salivation   Burning   Hydroa   Blisters

Mucus   stringy   Yellow   Gray   White

Lips - check all that are a problem for you.

Swollen   color

eruption   dry/parched        burning

growths   pain   cancer   hair lip

Stomach Symptoms - Check all that are a problem for you.

Difficulty swallowing   Liquids   solids dry swallowing

Feels closed  Swollen    inflamed   purple

Thirsty     No thirst    Thirst at night

Sticking pain Feels like a splinter Dry makes cough

Hiccough Stomach Cramps Ulcer

Food cravings

Food Dislikes

Food Allergies

Other Cravings

Abdomen: Check all that are a problem for you.
Colic Distention Cancer of bowel
Gas Distended after eating Diverticulitis
Cramps bending double  Polyps
Pain spots on Peritonitis
Worse Worse anger Colitis

Describe any additional problems of the abdomen area.

Stool: Check all that are a problem for you.
Diarrhea constipation color
odor Linteric pencil lead
difficult involuntary dry/crumbling
charred/burnt looking green

Describe any additional difficulties with bowel movements or problems.

Urine: Check all that are a problem for you.
Difficult must press out cannot when others are present
burning feels like a ball bladder feels full
painful prolapsed prostate problems
cancer    

Frequency - How many times a day
Color
Odor

Describe any other difficulties with urination - box will expand.


Kidneys:
stones cancer burning difficult to turn in bed
pain lower back pain anger makes worse
operations    

Date of Operation:
Describe what was done:


Male:
impotence satyriasis plays with person
masterbatic prostate cancer
urethra penis coition
HIV/Aids  Masculine Feminine
Sexual attraction to children homosexual tendencies itching
syphilis    

 List other information or diseases 

 Growths- Describe and give location:

Female: Check all that are problems.
impotence nymphomatic masterbatic
ovaries Uterus prolapsed
Vagina Labia clitoris
cysts cancer cervix
fallopian tubes itching Sexually transmitted diseases
HIV/aids Feminine Masculine

Give a description in the box below to explain any of the above problem areas.. Box will expand to accommodate your text.

Growths- Describe and give location:

Hysterectomy    Date of Hysterectomy:

Tubal Ligation   Date of Tubal Ligation:

Menses - Describe color, odor, appearance, frequency, amount 

Discharge Describe:

Chest / Lungs check all that apply

Asthma  Cough  humid worse 

sputum   color odor bloody

Tuberculosis   Lung Cancer  Emphysema

Respiratory - check all that are a problem for you.
hoarseness  scraping  shallow  laryngitis 
loss of voice  mouth breathing   Pleurisy   
Other

Back - check all that are a problem for you.
pain  location: between scapula  under scapula
right  left  middle  lower upper
over kidneys tailbone  injury 
auto accident other accident Must sit up to turn in bed
bed feels too hard 

Other - check all that are a problem for you.
worry about money Lost Love  Grief  eruptions
Loss of position/job/home  embarrassment
Death of a loved one/Pet 
Worse sitting   Worse standing  Worse lying down
Worse exertion Worse bending over Worse lifting

Sleep  
Position
Dreams
Eyes open during snores  mouth open

Skin - check all that are a problem area for you.
rashes ringworm  spots  sores/ulcers erysipelas
fungus  cancer/growths/warts/moles
location:
Hansen's disease
cysts/tumors/fibroids/keloids
itching 
other:

Muscles - check all that are a problem for you.
aches all over  Rheumatic fever  Fibromalgia
Muscular Dystrophy  Cystic Fibrosis  Multiple Sclerosis
Spasms/Cramps   
location:
chill    perspiration  night sweats  
odor   profuse         absent

Glands - check all that are a problem for you.
axiallry         swollen   
Where are glands swollen?
Addison's disease
Lymphoma  Lymphatic cancer Hypothryroid  throidectomy
parathyroidectomy  Hyperthyroid  Goitre
Other lymphatic disease:

Where were you born?: (Mountains, Desert, Ocean)
Where do you live now?: (as above)
Better where?:

Organs - check all that are a problem area for you.
Liver  right lobe  left lobe  pain
Spleen  Appendix  Exposed to poisons / armed services
Thymus  Pancreas  Gall Bladder  Bowel  Adrenals
Lungs  Veins  Arteries  Duedenum
Knees  Joints  Arthritis  Rheumatism  Osteoporosis

Feet - check all that are a problem for you.
Ankles  Calves  Toes  Achilles Tendons  Soles
Callosities  Corns
Nails: Color: Appearance:

Hands/Arms-Brief Description
Hands: Color: Appearance:
Nails:   Color: Appearance:
Wrists: Fingers:
Elbows:

Legs - check difficulties you have with your legs.
Cramps  Eruptions  Swelling

Modalities - Describe-box will expand to accommodate your text.

Worse - When are your symptoms worse - morning, evening, heat, cold, wet weather, dry weather, etc.  Describe what makes your condition worse.


Better - When are your symptoms better - morning, evening, heat, cold,


Generalities

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Doctors Health Supply
261 Conway Drive
Fountain Inn, SC 29644
along with a copy of your email receipt and waivers.