Final Questionnaire

PLEASE READ THIS BEFORE FILLING THIS FORM

YOU HAVE COME HERE TO GET WELL SOON. WE ARE HERE TO SELECT THE POSSIBLE MEDICINE FOR YOU.IN ORDER TO DO THAT, WE DEPEND ON YOUR CO-OPERATION. HOMEOPATHIC MEDICINES ARE TOTALLY BASED ON THE SYMPTOMS YOU PROVIDE US. IF WE ARE TO MAKE A SUCCESSFUL PRESCRIPTION; WE MUST KNOW ALL ABOUT YOUR SICKNESS. WE MUST ALSO ALL THE FEATURES THAT BELONG TO YOU AS AN INDIVIDUAL. THIS INCLUDES YOUR REACTIONS TO VARIOUS FACTORS; YOUR PAST AND YOUR MENTAL MAKE UP.

THIS INFORMATION ENABLES US TO SELECT THE REMEDY THAT REMOVES YOUR SICKNESS.

IN ORDER TO FIND EVERYTHING ABOUT YOU.WE SHALL BE ASKING YOU MANY QUESTIONS, EACH ONE OF THESE QUESTIONS HAS A DEFINITE MEANING AND SIGNIFICANCE FOR US. THERE IS NOT A SINGLE QUESTION WHICH IS USELESS. EVEN SOMETHING THAT YOU THINK IS NOT CONNECTED WITH YOUR SICKNESS, MAY BE THE MOST IMPORTANT FACTOR IN DECIDING THE CORRECT HOMEOPATHIC MEDICINE. THAT IS WHY YOU MUST FREE AND FRANK IN GIVING US THE ACCURATE INFORMATION ON EACH POINT. PLEASE READ EACH QUESTION CAREFULLY, THINK AND IF NECESSARY, CONSULT SOMEONE WHO IS CLOSE TO YOU AND THEN ANSWER COMPLETELY. DO NOT KEEP ANYTHING BACK.

REMEMBER EVERYTHING YOU WILL TELL US WILL REMAIN ABSOLUTELY CONFIDENTIAL.

Step 1 of 4

Family History


Provide information about them in the table below. Indicate yourself by writing ‘self’.

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Have your blood relatives had any of the following? If yes, please mark the box.

Personal History


Review of Systems:

Do you CURRENTLY have any of the following? If the answer is yes, please mark the box

Past Medical History:

Past Surgical History:

Past Endoscopic History:

Have you had any of the following endoscopies? If the answer is yes, please mark the box, and complete the additional spaces.

Did they find Polyps