Homeopathic Questionnaire

Homeopathic Questionnaire:

Thank you for choosing Homeopathic services at Aura Health Concepts.
Please try to give us as much information as possible against the columns.
If you wish to inform anything concerned to your health which is not asked here, you can do so in the additional information box at the end of this form.
Fields with red star (*) are compulsory.

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Name *

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Phone Number *

Email *

How did you know about us? *

How would you like to do your consultation? *

Enter your Skype ID & your phone number if it is different to the one given earlier: *

Upload any clinical reports or photos of your condition *

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Chief Complaints: Reason For Consultation *

Mention if exposure to particular elements makes your symptoms worse or better (like any particular food, weather, time of day, seasons, sunlight etc) *

History of Present Illness: Details like when did it start and how did it start? *

Are the symptoms constant or periodic? *

Are you under any medication for the present complaint or any other health issue? Please describe *

Mention any frequently occurring symptoms which are minor concerned to you, like headaches, indigestion, diarrhea, skin rashes, hay fever, cramps, urine infections etc… *

Try to estimate the severity of your problem considering both intensity and frequency: *

History of Past Illnesses: (Mention if you have suffered with any major health issues in the past and medications used) Like Typhoid, Jaundice, Viral infections etc... *

Family History: (Mention if your Parents, Grand parents, Paternal or Maternal Aunts or Uncles, sisters, brothers had experienced similar or any other major health issues. *

History of Allergies since childhood. Please explain *

Any particular type of weather you are more comfortable in? *

System Analysis:

Please mention if you experience any of the symptoms or conditions listed under each system. You may also explian the symptoms you are experiencing that are not mentioned here.

Digestive System: Indigestion, heart burn, bloating, refluxes, ulcers, excessive burps, offensive breath , constipation , frequent diarrhea, wind, thirstlessness, poor appetite, excessive thirst, excessive hunger, cravings , aversions to certain foods etc., conditions involving liver, gall bladder, pancreas and spleen. *

Respiratory system: Frequent colds, Chronic cough, sore throat, breathing difficulties, hay fevers, asthma, bronchitis, sinusitis, polyps, tonsillitis etc. *

Urinary system: Infections, cystitis, burning urination, frequent urination, incontinence, stricture of urethra, renal calculi (kidney stones): *

Circulatory system: Cardiac (Heart) problems, poor peripheral circulation, varicose veins, hypertension, low blood pressure, high blood pressure etc *

Skin: Warts, corns, cracks, scales, discoloration, itching, eruptions, hives, allergies, freckles, scars, tumors, moles, dandruff, hair fall, acne, pimples, early wrinkles, excessive sweat, sweating on single parts: *

Musculoskeletal system: Pains, chronic pains, frequent sprains, swellings, tumors, arthritis, osteoporosis, disc prolapse, back ache, head aches, migraines, cramps, injuries, fractures, dislocations, concussions, cerebral hemorrhage, caries of bone, fibromyalgia, chronic fatigue etc *

Mind: Anxiety ,nervousness, restlessness, forgetful, weak memory, poor concentration, fears, anger easily, impatience, aversion to people, things or daily business, depressed, confusion of mind, speech difficulties, perverted thoughts, low in courage, do you desire normally desire for company or loneliness, grief, hurry in doing things, easy exhaustion of mind, delusions ,hallucinations etc *

Sleep: Disturbed, restlessness, unrefreshed sleep, late night sleep, talking or walking in sleep, sleeplessness, grinding of teeth in sleep, startle in sleep. *

Sexual Male: Loss of erections, decreased desire, premature ejaculation, emissions in sleep, history of any sexually transmitted diseases, prostate enlargement. *

Sexual Female: Decreased desire, any sexually transmitted diseases, irregular periods, excessive bleeding, and history of abortions, tumors, and endometriosis etc *

Additional Information: *

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