Adult Intake Form for Homeopathy


Natural Treasure Holistic medicine
Mohamed El Siddig , NSHS, DMHS ( HD)
Homeopathic Doctor & Healer
Hypnopath/ Psychopath
Hamilton ,ON
Barton East
2892441179

Homeopathic consultation is facilitated when there is a complete picture of the individual’s mental, emotional and physical states of health.  This includes symptoms that affect both physical sensations (what does it feel like), and function (how it impacts you) and what ameliorates or aggravates each symptom.

Date

Your Name (required)

Age

Birthdate

Sex

Address

City

Province

Postal Code

Phone (home)

Phone (work)

Phone (Cell)

Your Email (required)

Occupation

Full-time/Part-time/Retired/None?

Employed by

Education

Marriage Status

Are you familiar with or have you ever had Homeopathic treatment?

If yes, what remedies have you taken and what remedies have helped?

In your opinion, what are your most important health problems? List as many as you can, in order of importance:

1. 4.

2. 5.

3. 6.


Past Medical History:

When did your complaint or ailment begin?

What do you think causes or has caused your ailment or complaint?

Have you had an experience (traumatic, illness, vaccine or other) that did or still affects you deeply? Explain.

The general state of my health has been:
 Excellent Good Fair Poor

What childhood illnesses have you had?
 Rubella (3 day-measles) Mumps Chickenpox Measles (2 weeks) Whooping Cough Asthma Scarlet Fever Rheumatic Fever Other

If other:

If you have had any of the following tests or immunizations, place a (check) on the appropriate line and/or give the (approximate) year.

 Chest x-ray
Year:

 G.I. Series
Year:

 Colon x-ray (Barium enema)
Year:

 Kidney x-ray
Year:

 Electrocardiogram
Year:

 MMR
Year:

 Smallpox
Year:

 Tetanus
Year:

 Polio
Year:

 Typhoid
Year:

 Diphtheria
Year:

 Flu
Year:

 Other
Other:
Year:


Your Health History:

Addictions:  Now Past Never

Alcohol:  Now Past Never

AIDS:  Now Past Never

Allergies:  Now Past Never

Anemia:  Now Past Never

Anorexia:  Now Past Never

Asthma:  Now Past Never

Bleeding:  Now Past Never

Bruising:  Now Past Never

Bulimia:  Now Past Never

Cancer:  Now Past Never

Colitis:  Now Past Never

Convulsions:  Now Past Never

Depression:  Now Past Never

Obesity:  Now Past Never

Rheumatism:  Now Past Never

Thyroid:  Now Past Never

Diabetes:  Now Past Never

Drugs:  Now Past Never

Eczema:  Now Past Never

Emphysema:  Now Past Never

Epilepsy:  Now Past Never

Gout:  Now Past Never

Heart Condition:  Now Past Never

Hepatitis:  Now Past Never

Herpes:  Now Past Never

Hypertension:  Now Past Never

Kidney Disease:  Now Past Never

Liver Disease:  Now Past Never

Mental Disease:  Now Past Never

Migraines:  Now Past Never

Pneumonia:  Now Past Never

STD:  Now Past Never

Tuberculosis:  Now Past Never


Hospitalizations: List as best as you can.

1.
Type of illness/operation:

Date:

Where:

2.
Type of illness/operation:

Date:

Where:

3.
Type of illness/operation:

Date:

Where:


Do You Use:

 Coffee
Amount:

 Cigarettes
Amount:

 Alcohol
Amount:

 Aspirin
Amount:

 Other Drugs
Amount:

 Birth Control Pills
Amount:

 Sedatives/Tranquilizers
Amount:

 Thyroid
Amount:

 Laxatives
Amount:

 Cortisone
Amount:

 Electric Blanket
Amount:

 Hormones
Amount:

 Herbs/Teas
Amount:

 Vitamins
Amount:

 Recreational drugs
Amount:

 Other therapies
Amount:


Are you allergic to any drugs (penicillin, etc.) Are you allergic to foods or other substances?

What happens when you have an “allergy attack” or “sensitivity reaction”?


Family History

Please list ages, and if deceased, what was the cause and at what age:

Your mother
 Living Died
Cause:

Age:

Your father
 Living Died
Cause:

Age:

Your brother(s)

Your sister(s)

Mother's side

Your grandfather
 Living Died
Cause:

Age:

Your grandmother
 Living Died
Cause:

Age:

Father's side

Your grandfather
 Living Died
Cause:

Age:

Your grandmother
 Living Died
Cause:

Age:


Has any blood relative had any of the following?

Allergies:
 Yes No Don't Know

Anemia:
 Yes No Don't Know

Arthritis:
 Yes No Don't Know

Asthma:
 Yes No Don't Know

Bleeding:
 Yes No Don't Know

Cancer:
 Yes No Don't Know

Diabetes:
 Yes No Don't Know

Depression:
 Yes No Don't Know

Eczema:
 Yes No Don't Know

Glaucoma:
 Yes No Don't Know

Gout:
 Yes No Don't Know

Hay Fever:
 Yes No Don't Know

Heart Attack:
 Yes No Don't Know

High Blood Pressure:
 Yes No Don't Know

Seizure/Epilepsy:
 Yes No Don't Know

Sickle Cell Anemia:
 Yes No Don't Know

Stroke:
 Yes No Don't Know

STD:
 Yes No Don't Know

Thyroid Trouble:
 Yes No Don't Know

Tuberculosis:
 Yes No Don't Know


Symptoms: Please mark 1 (mild), 2 (moderate), 3 (severe) if any of the following apply to you NOW or in the PAST.

skin: rough:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

skin: dry:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

skin: scaly:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

skin: bumpy:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

skin: itchy:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

rashes:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

warts:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

moles:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

cysts:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

light patches of skin:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

dark patches of skin:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

increased hair growth in unusual places:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

pimples:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

color changes in nails:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

hives:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

loss of hair:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

ridges, pits or spots on nails:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

ridges, pits or spots on nails:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

infections, fungal symptoms:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Blood, Lymph, Immune

Swollen or painful lymph nodes:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Wounds heal slowly:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Difficulty stopping bleeding:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Swollen glands:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Bruise easily:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Endocrine

Excessive hair growth:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Prefer cold weather:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Weakness:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Cold hands or feet:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Can’t stand cold:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Chronic fatigue:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Unexplained thirst:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Increased hunger:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Can’t stand heat:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Profuse sweating:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Head

Dizziness:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Severe headaches:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Seizures/tics/spasms:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Double vision:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Fainting spells:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Injuries:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Eyes

Infections:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Blurred vision:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Sensitive to light:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Near/far sighted:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Floaters:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Injuries:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Nose

Nose bleeds:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Sinus problems:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Injury:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Loss of smell:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Obstruction - difficulty breathing through nose
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Mouth

Sore mouth or tongue:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Infections:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Loss of teeth:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Bad breath:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Gum disease:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Speech difficulties:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Throat

Persistent hoarseness:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Difficulty swallowing:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Loss of voice:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Pain:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Infections:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Swelling:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Neck

Stiffness:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Injuries:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Swelling:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Respiratory

Unexplained fever:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Chest pain:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Wheezing:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Infections:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Night sweats:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Shortness of breath:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Daily cough:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Difficulty breathing:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Difficulty breathing at night (wakes you up):
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Cardiovascular

Chest pain when walking:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Ankle-swelling:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Shortness of breath:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Varicose veins:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Hypertension (HBP):
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Leg pain (walking):
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Heart palpitations (fluttering, pressure, skipping, rapid beat):
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Digestive System

Frequent or severe symptoms:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Blood in stools:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Change in bowel movements:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Heartburn:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Vomiting, nausea:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Hemorrhoids:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Black stools:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Vomiting blood:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Indigestion:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Excessive belching:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Stomach pain:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Anal itching:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Yellow jaundice:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Difficulty swallowing:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Distress from fats or greasy foods:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Stools yellow, clay-colored, foul odored, has undigested food:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Bad breath, bad taste in mouth; body odor (including feet):
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Indigestion after meals (fullness, bloating, sourness, etc.):
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Heavy, full feeling after eating:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

History of constipation or diarrhea:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Excessive lower bowel gas:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Stomach pain occurs 5 or 6 hours after eating:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Indigestion occurs immediately after eating:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Nervousness, shaky feelings, headaches, relieved by eating:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Irritable if late for meal, miss meal, or before eating breakfast:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Sudden, strong craving for sweets or alcohol:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Wake up at night feeling hungry:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Overweight:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Sudden weight loss:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Infection:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Loss of appetite:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Sudden weight gain:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Injury:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Sleepy during the day? :
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)
When?:

How often do you have bowel movements?:

Do you strain at stool?:
 No Yes

Have you had a change of appetite?:
 No Yes
Has your appetite Increase or Decrease?:
 Increase Decrease

What does your diet consist ?:

Do you snack?:
 No Yes
If so, what are your snacks?:

What foods, condiments, or any other substances (i.e. chocolate, ice-cream, mustard, sour, spicy, etc.) do you crave?:

Are you repelled by, or do you dislike any foods?:

Are there any foods that trouble or aggravate or do not agree with you? In what way?:

Are you thirsty for:
 Hot Drinks Cold Drinks

Ice in your drinks?:
 No Yes
Do you like to chew ice?
 No Yes


Urogenital System

Frequent urination:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Night urination:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Trouble starting urine:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Frequent urging with scant urination:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Painful urination:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Trouble holding:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)


Male Problems

Any prostate problems:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Discharge from penis:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Difficulty achieving or maintaining an erection:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Painful erection:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Difficulty with ejaculation:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Lumps, swelling or pain in testicles:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Infection:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Infertility:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Injury:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Female Problems

Discharge from vagina:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Difficulty feeling sexually aroused:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

No lubrication when aroused:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Never or seldom have orgasms:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Sex is painful:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Pelvic pain:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Menstrual flow is excessive:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Menstrual flow is absent:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Bleeding or spotting between periods:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Pain
 before during after:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Infection:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Infertility:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Lumps in breast:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Premenstrual symptoms:
 cramping water retention tenderness headaches depression irritability:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)


Spine and Extremities

Joint pain, swelling, stiffness, tingling, numbness:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)
Where?

Muscle cramps:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Burning soles of feet:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Unusual redness of palms of hands:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Injuries:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Backaches:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Other:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Other:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Have you ever had arthritis?:

 No Yes
Where:

What kind:


Nervous System

Loss of balance:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Lack of strength (seizures, stiffness):
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Convulsions:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Paralysis:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Numbness:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Tremor (shaking, involuntary movements, tics, spasms):
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

General

Are you a warm or chilly person?:
 warm chilly

Are you sensitive to changes in weather?:
 no yes
Sun?
 no yes
Drafts?
 no yes
Wind
 no yes
Noise
 no yes
Ordered environment
 no yes
Other

When in bed, if you feel warm, what part of your body would you tend to uncover first?

Do you usually dream?
 no yes
If so, what do you dream about?


Mental Emotional

Restlessness:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Excessive worry:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Memory trouble:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Depression:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Trouble sleeping:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Anxiety:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Nervousness:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Trouble concentrating:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Crying spells:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Trouble getting along with people:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Easily angered:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Mood swings:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Feelings of worthlessness:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Suicidal thoughts:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Fearful:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Excess stress:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Loss of someone dear through death or separation:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Always put others’ interests before yours:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

See things that others don’t:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Hear voices:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Think others want to hurt you:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Don’t know how to relieve stress:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Is order important to your surroundings?:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Are you generally late for appointments?:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Do you tend to leave things undone until the last minute?:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)

Peculiar sensations?:
Now  1 (mild) 2 (moderate) 3 (severe)
Past  1 (mild) 2 (moderate) 3 (severe)
What?

Where?

How do symptoms of stress show up in you (physically/emotionally)?

What are your triggers for stress?

How do you alleviate stress?

Is there anything else you wish to add?

Homeopathic Disclosure & Informed Consent

Homeopathy is considered to be an alternative/preventative system of health care and is not intended to be a substitute for allopathic or traditional medicine.

The therapy and information offered should not be construed by you, the client, or any family, friends or caregivers to be a medical diagnosis of any disease or injury.

You should consult with your physician for any serious medical condition and further, you should get at least two medical opinions for such condition.

While Mohamed El Siddig ,DHMS , DMLS , ( HD) ,CMA member has had extensive training in the science and art of Homeopathy .

I understand that a homeopathic remedy may be given with this consultation or be suggested for purchase at a store of my choosing.

If given at the time of consult and needed to be repeated before the next consult, a $10.00 remedy fee (plus shipping if necessary) will be charged.

I confirm that any prescription medications I am taking under the care of a physician will not be withdrawn without his/her supervision.

I understand that a block of time has been set aside for my private appointment and that a 24-hour notification is required if I must cancel.

I understand that there is a fee of one consult hour ($50.00) for appointments canceled less than 24 hours in advance.

I understand that payment is due at the time services are rendered, unless other arrangements have been made prior to the appointment.

I understand that phone consultations will be billed at the usual hourly rate.

I understand that current fees for single consultations are as follows, but that there may be changes in the fee structure in the future.

Initial Single Consultations $100.00 (120 minutes)
Follow-up Single Consultations $60.00 (60 minutes)

I HAVE READ THE ABOVE AND AGREE TO ALL TERMS:

Signature

Do you agree?