Two Legs and Four Holistic Health Adult Questionnaire

Two Legs and Four Holistic Health - Adult Questionnaire
In order to make an accurate prewscription, I depend on your co-operation. Homeopathic treatment is mainly based on the symptoms you provide me. If I am to make a successful prescription, I must know all the details of your problems. I must also understand you as an individual, including your reactions to stress, your past, your family history, your nature and your mental make up.

The information you provide enables me to restore your health.

In order to achieve this, I shall be asking you many questions. Each one has great significance to me, even those you may consider irrelevant to your health issue. This is why you need to be frank and free with all the relevant information.

Please read each question carefully. Don't keep anything back. If necessary, ask someone close to you for more information.

Everything you tell me is in complete confidence. This questionnaire is not obligatory.

This is a lengthy questionnaire, so be prepared to take time to fill it out.

You can save the document to complete later. Make sure you click on 'Submit' at the end.

You can fill out as much or as little as you desire. However, the more info I have the better able I can help. Health is complicated and many factors contribute to ill health. Homeopathy examine every possibility.
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

If you are an immigrant


Where from
How long have you lived here
Are you homesick?
Are you settled?

Any other commenst
What is your marital/relationship status?

Married/partnerSingleDivorcedWidowed
What is your education?
What is your occupation?
Are you adopted?
Were you conceived by IVF, surrogacy or sperm donation?
Are you religious and/or spiritually inclined?
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 drugsOtherNone
Comments
Please indicate dosage and duration of any drugs
Please indicate any past drug use, duration and repetition.*
Please list any health supplements
Your Digestion
How is your appetite?
Are you able to fast?
What is your NATURAL thirst.
Are you omnivore, vegetarian, lacto-vegetarian, pesco-vegetarian, vegan, fruitarian, etc
Please indicate the foods you love or find difficult to do without.
Please indicate the foods you hate or are aggravated by
Digestion

Do you bloat?Do you suffer with heartburn?Do your burb?Do you have diarrhoea?Do you pass gas ?Are you constipated?Do you take laxatives?Other
You can elaborate here
Your Body
Please indicate factors that affect you, then explain further in the comments.
Sweat, perspiration

Do you sweat on your head/hair?Do you sweat on your back?Do you sweat on your chest?Do you sweat on your palms?Do you sweat on your soles?Do you sweat excessively?Do you barely sweat?Does the sweat smell unpleasant?Other
You can elaborate here
Your Sleep
Please detail sleep patterns
Please indicate the type of dreams you have.
Your Sexuality, Hormones

Please give details of your sexuality.*


Are you sexually active?
Are you in a committed relationship?
What protection do you use for disease/pregnancy?
Do you have any sexual discomfort?
Have you ever had an STD?
Have you ever been the victim of rape or incest?
Do you have homosexual preferences?
Do you masturbate?
Is your sexuality high, medium, low?
Do/did you have any sexual indulgences?
How do you feel after sexual intercourse?

You can elaborate here

Sexuality in men*


Do you have any difficulty in erections?
Do you have difficulty maintaining an erection?
Do you suffer with premature ejaculation?
Do you have nocturnal emissions/wet dreams?
Other

You can elaborate here

Sexuality in women*


Do you suffer with dryness/discomfort/bleeding?
Do you have abdominal discomfort after intercourse?
Other

You can elaborate here

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
Please give details of your nature and things that affect you
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.
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 give details here
Please indicate any vaccines you have had.

DTPDTaPPolioPetussis/whooping coughMMRChicken poxHIBHep A or BPCVBCGMalatiaYellow feverCholeraGamma globinFluTetanusHPV/GardasilCovidOther
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.
Please detail major health issues in your family history - siblings, parents, grand parents, aunts, uncles, cousins with the age of death..
Please detail anything you know about your mother's pregnancy and birth with you including any medical interventions and how it was for your mother. Was she able to feed you?
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 Digestion

Your Body

Your Sleep

Your Sexuality, Hormones

Your Nature, Mind

Your Past

Thank you!

Re-scheduling or Cancellations