ARIZONA HOMEOPATHY, Over 35 years of longstanding experience in classical Homeopathy, Questionnaire

Over 35 years longstanding experience in classical Homeopathy

For personalized homeopathic care in Phoenix, Arizona please call:
(602) 909-9969

Homeopathic Questionnaire

"If you would like to schedule an appointment, please fill out this form and we will get in touch with you shortly."

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General Information
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Marital Status
Date of Birth*
MM
DD
YYYY
Gender*
- Male
- Female
Height*
Occupation
Weight*
Family Physician
Referred By
How did you hear about us?*
Medical History
List Childhood Diseases
Vaccinations

List adverse or unusual reactions after vaccination
Medication(s) you are currently taking
Medication(s) taken in the past
Homeopathic remedies (including Potency) you are currently taking
Homeopathic remedies (including Potency) taken in the past
Have you ever had any surgeries?
- Yes
- No
If yes, please name the surgery type and when
Have you ever had cancer?
- Yes
- No
If yes, please identify the type of cancer and when
Do you have any unusual or peculiar symptoms?
- Yes
- No
If yes, please describe
Allergies ( Hold the CTRL key to select multiple items.)
If food or other, please list them here
Do you have any personal habits?
(like alcohol, smoking, recreational drugs, etc.)

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Family Medical History
List any genetic diseases
Mother - Alive
- Yes
- No
If No, age at death and cause of death
Father - Alive
- Yes
- No
If No, age at death and cause of death
Disease of Grandparents on both sides (if known)
Main Complaints
Brief Description of Main Complaint(s)
When did the problem(s) begin?
What happened in your life around that time?
At what time of day is the main complaint worse?
What aggravates the main complaint?

(e.g. certain foods, weather, movement, light, noise, heat/cold, others)
What symptoms accompany the main complaint?
At what time of day is the main complaint better?

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Head
Check all that apply ( Hold the CTRL key to select multiple items.)
Heart
Check all that apply ( Hold the CTRL key to select multiple items.)
Blood Pressure
(if you don't know exact, list whether high or low)
Chest/Lungs
Check all that apply ( Hold the CTRL key to select multiple items.)
Throat
Check all that apply ( Hold the CTRL key to select multiple items.)
Kidneys
Check all that apply ( Hold the CTRL key to select multiple items.)
Eyes
Check all that apply ( Hold the CTRL key to select multiple items.)
Nose
Check all that apply ( Hold the CTRL key to select multiple items.)
Mouth
Check all that apply ( Hold the CTRL key to select multiple items.)
Ears
Check all that apply ( Hold the CTRL key to select multiple items.)
Face
Check all that apply ( Hold the CTRL key to select multiple items.)
Stomach
Check all that apply ( Hold the CTRL key to select multiple items.)
Other gastro-intestinal complaints, food cravings, and/or food aversions
Abdomen
Check all that apply ( Hold the CTRL key to select multiple items.)
Rectum
Check all that apply ( Hold the CTRL key to select multiple items.)
Urine
Check all that apply ( Hold the CTRL key to select multiple items.)

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Female
Check all that apply ( Hold the CTRL key to select multiple items.)
What, when, and how treated?
Menstrual Cycle
Frequency
Duration
Check all that apply ( Hold the CTRL key to select multiple items.)
Ailments before menses:
(if applicable)
Have you had a Hysterectomy? When?
Have you been through Menopause? Age?
Male
Check all that apply ( Hold the CTRL key to select multiple items.)
What, when, and how treated?

(sexually transmitted disease)
Back
Check all that apply ( Hold the CTRL key to select multiple items.)
If any, please describe
Sleep
Position you sleep in
Do you tend to wake up at a particular time during the night?
Recurring dreams (if applicable)
Check all that apply ( Hold the CTRL key to select multiple items.)
Skin
Check all that apply ( Hold the CTRL key to select multiple items.)
Muscles
Check all that apply ( Hold the CTRL key to select multiple items.)
Glands
Check all that apply ( Hold the CTRL key to select multiple items.)
Extremities
Check all that apply ( Hold the CTRL key to select multiple items.)
List additional complaints here
Untitled

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