Name: ______
San Diego Homeopathy
Tel: (858) 531-5279
Fax: 1800-661-3305
......
adult QUESTIONNAIRE
First name: / Last name:Date of birth: / / / Today’s date:
Address: / Sex (Circle): Male Female
City: / Height: Weight:
ZIP:
Home telephone: / Work Telephone:
Cell phone/pager: / Website:
Emergency contact: (Name, relationship, Address, Tel)
Email address: / Occupation:
Religion: / Contact details for primary doctor:
MARITAL STATUS (Circle)
Single, Married, Gay, Divorced, Separated, Widowed, Domestic partnership
How did you find out about me? ______
______
Thank you for taking the time to fill out this questionnaire.
It is designed to help me understand your problem and to understand you as a person.
It is also aimed at giving you a greater awareness of your symptoms,
making it easier to relay them to me during our consultation.
Looking forward to meeting you.
Please type or write neatly.
You may fax, hand deliver, mail or email this questionnaire
to the clinic, or bring it along with you to your visit.
THIS REPORT WILL BE TREATED AS STRICTLY CONFIDENTIAL
Section A: MAIN COMPLAINT
Please describe your main complaint(s) in as much detail as possible. Note when it started, what makes it better or worse and what treatments you have tried? ______
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Name: ______
Section B: MEDICAL HISTORY
List any medication/ vitamins/ herbs or supplements you are currently taking:
DRUG / DOSAGE / INDICATIONDon’t forget to bring along any relevant medical records you have available.
List medicines you have taken frequently in the past or over an extended period of time.
DRUG / DOSAGE / INDICATIONList any surgeries you have had:
DATE / SURGICAL PROCEDURE / REASONWhat childhood illness/injuries did you have?
AGE / ILLNESS/ INJURY / REACTION TO ILLNESS e.g. frequency, reoccurences, severe, hospitalized, mildAGE / CHILDHOOD ILLNESSES / REACTION TO ILLNESS e.g reoccurrences, frequency, severe, mild hospitalization, etc
Have you had any of the following illnesses? Check all that apply:
Mumpsٱ Measlesٱ Chicken-poxٱ Polioٱ Glandular feverٱ Mononucleosisٱ Pneumoniaٱ Eczemaٱ Asthmaٱ Tuberculosisٱ Cancer ٱ Gonorrheaٱ
Which vaccinations have you had? Check all that apply:
Small poxٱ Polioٱ Mumpsٱ Measlesٱ Chicken poxٱ Tetanusٱ Hepatitisٱ Fluٱ ٱ Other
Have you had any vaccinations in the last year? Yesٱ Noٱ If Yes, describe:
______Have you ever had any reactions to vaccination? Yesٱ Noٱ If Yes, describe ______
Section C: FAMILY HISTORY
Please fill in the details of your family’s medical history. If you are adopted and do not know your family’s history please indicate so and leave out this section. Please fill in this section as best as you can. Many of you will not know all the details, and that is fine too.
Age / History of illness,current state of health / Age of death / Cause of death
Father
Mother
Brothers
Sisters
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Are there any illnesses that run in your family? ______
______
Is there any family history of: Please check: Tuberculosis ٱ Cancer ٱ Gonorrheaٱ Scabies ٱ
Section D: TIMELINE
Add to the lines below a chronological time line of your life. Add any significant events. Include the following:
· Turning points after which your health deteriorated. May have been after an illness, emotional trauma, accident or injury, a pregnancy, a drug, a period of heavy drinking, etc
· Significant physical traumas or injuries
· Significant emotional traumas (an abuse, loss of loved one, divorce, etc)
· Significant illnesses which deteriorated your health
______
______
______
______
______
Section E: DIET & LIFESTYLE
This is to find out what you typically eat during the day. Please answer this section as honestly as possible.
BREAKFAST:
Time:
Eat what: ______
Snack:______
LUNCH:
Time:
Eat what: ______
Snack: ______
SUPPER:
Time:
Eat what: ______
Before bed: ______
Do you wake up at night to eat/ drink? Yesٱ Noٱ Please describe: ______
Any foods that you strongly desire? ______
Any foods that you strongly dislike? ______
Any foods that make you ill? ______
If yes, what symptoms do you experience?______
Which of the following tastes do you desire the most? Check all that apply:
Sweetٱ Saltyٱ Sourٱ Spicyٱ Pungentٱ Picklesٱ Bitterٱ
Smoking:
Please check that which applies to you. Are you a:
Non-smoker ٱ Quit smoking ٱ How long ago? ______Smoker ٱ How many a day?______
Drinking habits:
How much alcohol do you consume a week? ______
What alcohol do you drink? ______
Drug use:
Which recreational drugs have you used in the past? ______
______
Which recreational drugs do you currently use? ______
______
How often do use recreational drugs? ______
Exercise:
Do you currently participate in any form of exercise? Yes No
If yes, what exercise and how often? ______
What do you enjoy doing for relaxation? ______
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Name: ______
Section F: General symptoms
Please CHECK the information that applies to you:
1) Are you? Thirsty ٱ Thirstless ٱ Some where in betweenٱ
2) What do you drink?______
3) Do you? Sip drinks slowly ٱ Gulp drinks down ٱ Neither ٱ
4) Do you prefer drinks that are? ice cold ٱ hot drinks ٱ room temperatureٱ
5) Is your appetite? Ravenousٱ Averageٱ Smallٱ Increasedٱ Decreasedٱ
6) Is your body temperature? Too hot ٱ Too cold ٱ Can’t stand heat /cold ٱ Not significantٱ
7) What weather are you best in?______
8) Is there any weather that aggravates you? ______
9) Is your perspiration? Extremeٱ Profuseٱ Averageٱ Slightٱ Not at allٱ
10) Where do you perspire from? ______
11) Please describe the odor of your perspiration as best as you can? E.g. sweet, metallic, musty, foul, etc ______
12) Does it stain your clothes? Noٱ Yesٱ If yes, what color? ______
13) What is you energy level like? Hyperactiveٱ Good energyٱ OK energyٱ No energyٱ
14) When is your energy best? ______
15) When is your energy at its worst? ______
16) Do you suffer from? (Check all that apply) Constipationٱ Diarrheaٱ Hemorrhoidsٱ
Gasٱ Bloatingٱ
17) Do you have any pain on urinating? Yes ٱ Noٱ
18) Do you suffer from urinary tract infections? Yesٱ Noٱ
19) Does your urine have a strong odor? Yesٱ Noٱ If yes, please describe ______
Section G: Skin & Nails
1) Check any skin conditions you have now or have had in the past?
Eczemaٱ Psoriasisٱ Wartsٱ Skin tagsٱ Cradle capٱ Athlete’s foot ٱ Ringwormٱ Scabiesٱ Impetigoٱ Acneٱ Acne rosaseaeٱ Hivesٱ Otherٱ
Describe these skin complaint(s) in detail, noting whether you suffer from it now or previously, as an adult or a child and the treatment(s) you’ve used? ______
______
2) Describe your fingernails: Crackedٱ Peelٱ White spotsٱ Fungusٱ Discoloredٱ Ridgedٱ
3) Describe your toe nails: Crackedٱ Peelٱ White spotsٱ Fungusٱ Discoloredٱ Ridgedٱ
4) Do you? Bite your nails ٱ Peel your nails ٱ
Section H: Sleep
1) How do you rate your sleep? Goodٱ Fairٱ Averageٱ Poorٱ Terribleٱ
2) Do you have difficulty falling asleep at night? Yes ٱ Noٱ
3) Do you wake up in the middle of the night? Yes ٱ Noٱ If yes, at what time(s)?______
4) Do you have difficulty falling asleep again? Yes ٱ Noٱ
5) Do you wake up feeling refreshed in the morning? Yes ٱ Noٱ
6) In what position do you sleep at night? ______
7) Do you do any of the following? Sleep walkٱ Sleep talkٱ Grind your teethٱ Snoreٱ
8) Are nightmares a problem for you? Yes ٱ Noٱ
Section I: FOR WOMEN to complete
1) At what age did your periods begin? ______
2) Your periods are? (Check all that apply) Regular ٱ Irregular ٱ Too earlyٱ Too lateٱ
Light flowٱ Medium flowٱ Heavy flowٱ
3) Describe the blood: (Check all that apply) Bright redٱ Dark redٱ Paleٱ Pinkٱ Clottedٱ Stringyٱ Membranousٱ
4) Do you have any pain associated with your period? Yesٱ Noٱ If Yes, describe the pain: ______Does it occur: (Check all that apply) Before ٱ During ٱ After menstruationٱ
5) Do you experience any physical, emotional or behavioral changes before, during or after your periods? Yes ٱ Noٱ If Yes, please describe: ______
______
6) Describe any symptoms during ovulation: ______
7) What type of contraception do you use? ______
8) Are you menopausal/ premenopausal? Yes ٱ Noٱ If Yes, describe any symptoms you are experiencing: ______
9) Have you had a hysterectomy? Yes ٱ Noٱ
10) Have you had an ovarectomy? Yes ٱ Noٱ
11) Are you on hormone replacement therapy? Yesٱ Noٱ
12) What is your libido like? Too high ٱ Too low ٱ No problems ٱ
13) Do you experience any pain on intercourse? Yes ٱ Noٱ
14) Do you have any bleeding on intercourse? Yes ٱ Noٱ
15) Do you experience vaginal dryness? Yes ٱ Noٱ
16) Do you suffer from yeast infections? Yes ٱ Noٱ
17) Do you feel sexually satisfied? Yes ٱ Noٱ
18) How often are you able to achieve orgasm? Alwaysٱ Oftenٱ Sometimesٱ Rarelyٱ Neverٱ
19) Does intercourse aggravate or ameliorate your condition? Please explain: ______
______
20) Is your sexual orientation an issue for you? Yes ٱ Noٱ
21) Has masturbation ever been an issue for you? Yes ٱ Noٱ
22) Are you troubled by vaginal discharges? Yes ٱ Noٱ If yes, please describe: ______
______
23) Have you ever had any sexually transmitted diseases? Yesٱ Noٱ If yes, please list:
______
24) Have you had any problems trying to conceive? Yesٱ Noٱ
25) How many times have you been pregnant? ______
26) Have you had any miscarriages? Yesٱ Noٱ If yes, how many? ______
27) Have you had any abortions? Yesٱ Noٱ If yes, how many? ______
27) What are the ages of your children? ______
Section J: FOR MEN to complete
1) Do you have any prostate problems? Yes ٱ Noٱ
2) Do you have any difficulty in obtaining or maintaining an erection? Yes ٱ Noٱ
3) Do you experience premature ejaculation? Yes ٱ Noٱ
4) Do you feel sexually satisfied? Yes ٱ Noٱ
5) How often are you able to achieve orgasm? Alwaysٱ Oftenٱ Sometimesٱ Rarelyٱ Neverٱ
6) Does intercourse aggravate or ameliorate your condition? Please explain: ______
______7) Is your sexual orientation an issue for you? Yes ٱ Noٱ
8) Is masturbation an issue for you? Yes ٱ Noٱ
9) Have you ever had any urethral discharges? Yes ٱ Noٱ If yes, please describe:
______
10) Have you ever had any sexually transmitted diseases? Yesٱ Noٱ If yes, please list:
______
Section K: FOR CHILDREN (Complete only if the patient is a child)
a) Mother's pregnancy
1) Did you have any difficulty falling pregnant? Yesٱ Noٱ
2) Do you have any other children? Yesٱ Noٱ If Yes, list ages: ______
3) Describe any problems you had during pregnancy? ______
______
4) Describe your emotional state during pregnancy, including any stresses that you had? ______
5) Check all that apply to describe your labor? Vaginal deliveryٱ Caesarian sectionٱ
Forceps deliveryٱ Used suctionٱ Episiotomyٱ Epiduralٱ Analgesicsٱ Fetal distressٱ Water birthٱ Home birthٱ Had midwifeٱ
6) Describe any complications during labor? ______
8) How long were you in labor for? ______
9) What did you use for pain relief during labor? ______10) Did you breastfeed? Yesٱ Noٱ If Yes, how long for: ______
11) Is bedwetting a problem for your child?
12) Is masturbating an issue for your child? Yesٱ Noٱ
13) What best describes your child's growth and development? Take into account age learning to walk, talk, etc. Failure to thriveٱ Slow to developٱ Average developmentٱ Developed fastٱ
PLEASE SEE NEXT PAGE
Section L: Your commitment to getting well.
(Please answer this section as honestly as possible)
Some of you have had your complaints for a long time. For those longstanding or "chronic" complaints, a level of commitment on your part is needed in order to get well.
1) How long have you had your complaint? ______
2) How long are you prepared to commit to homeopathic treatment in order to get well? ______
3) What changes in your diet or lifestyle are you prepared to make in order to get well (if no changes, please say no change)? ______
______
Section M: Payment policy:
Unless arranged ahead of time, payment is expected on the day of your visit. We accept most credit cards except American Express.
Section N: Cancellation policy
We believe in maintaining both respect of time for both our patients and ourselves. The homeopathic consultation is extremely thorough and takes a significant amount of time. This specific block of time is reserved for your full, uninterrupted session.
If you cannot keep a scheduled appointment, you must notify us a minimum of 72 hours prior to your scheduled time, or you will be charged for the appointment. If your appointment is on Monday, please notify our office no later than noon on the previous Thursday if you can’t make it.
I acknowledge that I have read and understood the 72 hour cancellation policy.
______
Signed Date
Credit card details:
Card type: ______
Card number: ______
Expiry date: ______/______/______
Last 3 numbers on the back of the card: ______
Billing zip code: ______
Section O: Please attach a recent photo of yourself.
THE END
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