Final Questionnaire


Congratulations! You are almost done booking your treatment at Dr. Singhal Homeo. We are here to select the right and the most effective medicine possible for you. In order to do that, we depend on your co-operation. Homeopathic medicines are totally based on the symptoms you share with us. If we are to make a successful prescription, we must know all about your sickness. We must also consider all the features that belong to you as an individual. This includes your reactions to various factors, your past, and your mental makeup.

This information enables us to select the remedy that removes your sickness effectively.

In order to get the best idea about your health status, the symptoms, and the appropriate Homeopathic medicine, we shall be asking you a few questions. Each one of these questions has a definite meaning and is significant for us to best understand your case. There is not a single question that 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 frankly and accurately provide us with 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. Please do not hide or skip anything which is asked in the points.

Don’t worry; all of your details remain absolutely confidential.

Step 1 of 4

Family History

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


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