Two Legs and Four Holistic Health Adult Questionnaire

Two Legs and Four Holistic Health - Adult Questionnaire
Date*

DayMonthYear
Name*

First NameLast Name
Preferred Name
Birth Date*

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Landline Phone

Area CodePhone Number
Cell/Mobile Phone

Area CodePhone Number
E-mail*
Connecting for consultation*

SkypeZoomMadeleine phones youVisit to clinicMadeleine visits youYou phone Madeleine
How did you hear about me*

Internet searchReferral by extended family memberReferral by friendAlready treating a close family memberOther
If other, please explain
Your Health Concerns
Tell me about your main health trouble, including when it started, whereabouts it is in the body, which side is affected, what the pain feels like. What is the sensation of the pain?*
Can you trace the origins to any particular circumstance - illness, medical procedure, incident, injury, etc?*
What are the factors that influence your trouble - weather, temperature, food, pressure, anxiety, etc. This is further explored later.*
Please indicate any other health issues you may have and describe them more in the comment section below, such as when, where, how often, duration, effect, what you do.
Please list the drugs you are currently taking.*

IVFOral contraceptive pillContraceptive injectionAntibioticsAntidepressantsStatinsNSAIDsEpiduralAnti-hypertensivesCancer treatmentSteroids/cortisoneSocial drugsPainNoneOther
Comments
Please indicate dosage and duration of any drugs
Please indicate any past drug use, duration and repetition.*
Your Body
Please indicate factors that affect you.
Your Sleep
Please detail sleep patterns
Please indicate the type of dreams you have.
Your Hormones

Menstruation*


What age did your periods start?
How many days do/did they last?
How often do/did they come?
Describe the flow - light, heavy, pale, clotted?
Is/was there any pain?
Where?
Before, during, after the period?
Do/did you suffer with moodiness or irritability at this time?
Do/did they affect your energy?
Is/was there an odour?
Are the stains difficult to wash out?
Other

You can elaborate here

Pregnancy, Children*


How many pregnancies have you had?
Did you suffer with morning sickness?
Were there any pregnancy complications?
Were the births induced?
Did you have any C-sections?
How long were the labours?
Did you suffer with post natal depression?
Could you feed your baby?
Have you had any miscarriages?
Have you had any abortions?
Did you have any food cravings?
Other

You can elaborate here

Menopause*


When did your menopause start?
Do/did you ?have hot flashes/flushes?
Is/was there any discharge?
Is/was there any vaginal discomfort?
Are/were the breasts tender at this time?
Was your libido affected?
Other

You can elaborate here
Your Nature, Mind
What are your greatest griefs?
Do you have unwanted thoughts?
What makes you angry?
What makes you anxious?
Please details your hobbies, interests, passions, what you love doing or are good at, , what books you like to read, what movies you enjoy, etc.
How does your future look?
Your Past

Every disease, poisoning, drug or injury leaves its mark and remains a weak point in the system, affecting us more than we may realise. Homeopathic treatment takes these details into consideration. Please give as much detail as you can.
Please indicate if you have had any known exposure to chemicals.

AsbestosLeadTinSulphurMercuryAluminiumOther
You can elaborate here
Please list any surgeries, blood transfusions, etc with approximate age/dates and recovery.
How were you as a child? What was your nature, fears, dreams, events with major impacts? How were your milestones, growth and development?
Thank you!

CONGRATULATIONS in completing this marathon questionnaire! This is a significant step in your journey to wellness.
If you have seen a homeopath before, please give details of the remedies and the effect.
If you have used homeopathic remedies yourself, please give details and the effect.
Re-scheduling or Cancellations

Homeopathic consultations take time. My appointments are lengthy to discover the core reason for your ill health. So cancellations or failure to make an appointment makes a big impact on my day. Inevitably there are times where you need to re-schedule your appointment. Wherever it is possible, I do appreciate you giving me as much notice as possible, at least 24 hours is preferred. Often, people ring me early in the day for an appointment and it is frustrating for us both when there is apparently no free slot, which ultimately becomes available.Those who fail to attend to a prearranged appointment or don’t give me 24 hour advance notice may be charged for the full consultation. I appreciate your consideration.
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Two Legs and Four Holistic Health - Adult Questionnaire

Your Health Concerns

Your Body

Your Sleep

Your Hormones

Your Nature, Mind

Your Past

Thank you!

Re-scheduling or Cancellations