homeopathic intake questionnaire

8/18/2019 Homeopathic Intake Questionnaire

1/4

Please answer the following questions that fit your general nature. They may seemirrelevant to your immediate health concerns however they are important to determineyour overall health picture. Please answer according to your current state. The doctorwill review this document with you to give room for further explanation of choices.

Key:N = Never F = Frequently B = Better W = Worse S = Sometimes

WEATHER

These weather conditions affect me negativelyClouds Sun Damp Dry Storms Wind Fog None

The change of weather affects meStrongly agree Slightly agree Neutral Slightly disagree Strongly disagree

I feel better in the following climates

Mountains Seashore Dry Wet Sunny Cloudy None Applicable

I am affected by seasons (circle all that apply) Yes No(B/W) Spring (B/W) Summer (B/W) Fall (B/W) Winter

ENVIRONMENT

I am affected by these sensationsBright lights Warm rooms Open air Loud Noises Drafts Strong odors

I am a ______ natured person Warm Cold Neither

I tend to become uncomfortable faster in a room that is (circle all that apply)Warmer than usual (80 degrees) Cooler than usual (60 degrees)

In general, I tend to perspire (circle all that apply)Never Only with exertion When heated When cold When nervous Easily

The part of my body where I tend to perspire the most is ___________________

TIME OF DAY

My worst time of the day is (mood, energy, symptoms, etc.) ___________________

My Best time of the day is (mood, energy, symptoms, etc.) ____________________

Health Through NatureHomeopathic Intake Questionnaire

www.healthTnature.com1


2/4

SLEEP

During sleep I can experience these symptoms (circle all that apply)Teeth Grinding Restlessness TalkingPerspiration

Laughing

Frequent Urination

Snoring

Nightmares

Recurrent Dreams Excess Heat or Cold-Where? ___________

My preference for sleep isWithout covers Partially covered Fully Covered (including head)With window open

Without Clothing

Fully Covered (Not including head)With air blowing

Arms or legs out of covers

My usual sleep position isRight Side Left Side On Back On Abdomen

FOOD PREFERENCES

I frequently crave the following flavors (circle all that apply)Sweet

Pungent

Sour

Salty

Bitter

Spicy

Smoked

Juicy

Refreshing

I strongly dislike these flavors (circle all that apply)Sweet Pungent

Sour

Salty

Bitter

Spicy

Smoked

Juicy

Refreshing

I frequently crave the following beverages/foodsAlcohol

Apples

Bacon

Bread

Butter

CheeseChocolate Coffee Pastries Eggs Fat Fish

Fruit Grains

Ham

Ice

Ice cream Indigestible thingsLemons/Lemonade Liquor

Meat

Milk

Nut buttersOysters

Pickles

Vegetables

Vinegar Other _______________

I completely avoid these foodsAlcohol Apples Bacon Bread Butter CheeseChocolate Coffee Pastries Eggs Fat Fish Fruit Grains

Ham

Ice

Ice cream Indigestible thingsLemons/Lemonade Liquor

Meat

Milk

Nut buttersOysters

Pickles

Vegetables

Vinegar Other ___________________

I prefer my food

warm/cold

neitherI prefer my drinks

warm/cold neither

I tend to be thirstyAlmost never Several times per day Several times per hours Always

I often have a abnormal taste in my mouth Yes/No




3/4

If so, what type Metallic Bitter Foul Sweet Other ___________________

MENTAL/EMOTIONAL STATE

I tend to worry about (circle all that apply)Tasks

Emotions

Financial Security

Health

Mental Functioning

Morals

Others well being

Religion

Social life

Social position

The futureWork

Selfishness

I am easily frightened Yes/NoI have strong fears of (circle all that apply)Animals

Being alone

Death

Becoming seriously IllFailure Falling

/Heights Ghosts Insanity Misfortune

Crowds People

Evil

Robbers SnakesSpiders

Darkness

Thunderstorms Water

Contagious disease/germsSomething terrible happening

I find it difficult to stick to a decision Strongly disagree Slightly disagree Neutral Slightly agree Strongly agree

I change my mind frequently about decisionsStrongly disagree Slightly disagree Neutral Slightly agree Strongly agree

When I am feeling sad or upset, at the very worst point, I needTo be completely alone To have someone nearby To be distractedTo vent about what I am feeling To have someone talk to me and console me

Regarding any past emotional traumatic events, I feelResolved grief

Dwell on past

Inconsolable

Remorse

GuiltOther: ________________________________

At my worst, the following makes me feel much better (circle all that apply)Rest

Massage/Pressure

Crying

Yelling

Music

DancingCompany Being alone Talking Quiet Darkness SunshineEating

Gentle exercise

Vigorous exercise

Exposure to heat

Exposure to cold

Anything else that consistently makes you feel better: _______________________Anything else that consistently makes you feel worse: _______________________

I consider myself (circle all that apply)Stingy

Overly Generous

Thrifty

Extravagant

Hurried/ImpatientSlow

Messy Fastidious

Calm

Restless

Always busy

Shy/timid Outgoing

Angry

Mild temperedLazy

Guilty Stubborn

Yielding Coward TalkativeQuiet Trusting Gullible Suspicious Overly confident Honest Bossy Lack of confidence Lack of moral sense




4/4

Others consider me as (circle all that apply)Stingy

Overly Generous

Thrifty

Extravagant

Hurried/ImpatientSlow Messy Fastidious Calm Restless Always busy Shy/timid Outgoing Angry Mild tempered

Lazy

Guilty Stubborn

Yielding Coward TalkativeQuiet

Trusting

Gullible Suspicious

Overly confident

Honest

Bossy

Lack of confidence

Lack of moral sense

My feelings with the people closest to me areLoving Affectionate Indifferent Resent Hatred

(If you have a partner/spouse) My feelings toward spouse/loverLoving

Affectionate

Dissatisfaction

Disappointment

Resentment

Hatred

Feelings toward disease/condition are

Optimistic

Doubtful of recovery

Discouraged

Fearful

Despair of recovery

My overall outlook on life isLove life

Indifferent

Bored

Weary of life

Desire death

Suicidal thoughts Suicidal disposition

My general mood is oftenMorose

Sad

Apathy/Indifference

Excitement

Exhilaration

I cryNever

When grieving

When sad

When angry

When happy Spontaneously

I am forgetful for the following (circle all that apply)Dates

Names

Numbers

What someone just said

What I just said

Words

I often make mistakes with (circle all that apply)Numbers

Words (reading)

Words (speaking)

Words (writing)

I am sensitive to (circle all that apply)Beauty

Criticism

Cruel Stories

Frightening things

MusicReprimand

Rudeness

Suffering of others

Being made fun of

How often do you have the following behaviorsAbusive (N/S/F) Biting (N/S/F) Breaking things (N/S/F)Contrary (N/S/F)

Cursing (N/S/F)

Disobedient (N/S/F)Insulting (N/S/F)

Rage

(N/S/F)

Rudeness (N/S/F)Striking others (N/S/F)

Striking Self (N/S/F)



homeopathic intake questionnaire

Documents