Nicky Rice

Homeopath For Kingston upon Thames

ON LINE HOMEOPATHY QUESTIONNAIRE

THIS Will BE A FORM

Name

Address

Postal Code:

Landline Phone No: Mobile No:
Email Address:
Occupation:
Status: Married Single Other
D.O.B: Age:
Main Presenting Symptoms:
Which Childhood Illnesses did you have?
Which Immunisations did you have? Were there any reactions to any of them?
Are You on any Medication? If Yes, what and for how long?
Have you had any Accidents? Please state what and when it happened.
Have you had any operations? Please state what it was and when it happened.
Have you ever smoked or taken recreational drugs?
Have you/ or do you currently suffer from any fears or phobias?
Do you suffer from any digestive complaints. Please give details
What do you like to drink? Please include alcohol intake.
Do you suffer from any allergies? (include any foods)
Have you ever suffered from any skin complaints?
FAMILY HISTORY
Please make a list of any illnesses/diseases that are present within your family including mental/emotional disturbances
Parents:
Grandparents
Siblings
Aunts/Uncles/Cousins
All information is given in strictest confidence.

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