Language
English (UK)
Two Legs and Four Holistic Health - Adult Questionnaire
Date
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Year
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Name
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First Name
Last Name
Preferred Name
Birth Date
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Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Landline Phone
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Area Code
Phone Number
Cell/Mobile Phone
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Area Code
Phone Number
E-mail
*
Connecting for consultation
*
Skype
Zoom
Madeleine phones you
Visit to clinic
Madeleine visits you
You phone Madeleine
How did you hear about me
*
Internet search
Referral by extended family member
Referral by friend
Already treating a close family member
Other
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?
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Can you trace the origins to any particular circumstance - illness, medical procedure, incident, injury, etc?
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What are the factors that influence your trouble - weather, temperature, food, pressure, anxiety, etc. This is further explored later.
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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.
*
IVF
Oral contraceptive pill
Contraceptive injection
Antibiotics
Antidepressants
Statins
NSAIDs
Epidural
Anti-hypertensives
Cancer treatment
Steroids/cortisone
Social drugs
Pain
None
Other
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.
Asbestos
Lead
Tin
Sulphur
Mercury
Aluminium
Other
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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