Sophie Knock, Natural Health Practitioner

A natural path to body harmony and well-being.

Tel: 01458 830293
Mob: 07826 191769
sophie@holistichomeopath.co.uk

Adult Homeopathy Questionnaire

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Sophie Knock - Holistic Homeopath

69a Roman Way, Glastonbury, Somerset, BA6 8AD
Email: sophie@holistichomeopath.com
Phone: 01458 830293 or 07826191769

Please fill in this form with as much detail as possible. All information is private and confidential.

 

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        Describe briefly your main reason(s) for consulting a homoeopath
        List any medication that you are currently taking ( including the contraception pill, vitamins and food supplements)
        Give details of anything that you are allergic to: foods, drugs, animals etc
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        Family Health History

        Please give details of the health history of your relatives. For example: Diabetes, heart disease, cancer, tuberculosis, thyroid, mental disease, suicide, alcoholism, etc. include father, mother, grandparents, brothers, sisters, uncles and aunts

        Personal Health History

        Please fill in this section giving as much information as possible including dates.  Remember to mention your approximate age at the time of any health problems.

        Infectious Childhood Diseases: (measles, mumps, chicken pox, whooping cough, glandular fever etc. / state if mild or severe)
        Any adverse reactions to immunisations/vaccinations?
        Injuries and accidents
        Operations and surgical procedures
        Skin: Warts, verrucae, herpes (cold sores), abscesses, boils, moles, eczema, impetigo etc.
        Weather & environment reaction: (what weather suits you best? Do you feel the cold/heat/wind/drafts/damp/humidity? Do you prefer warm rooms or desire fresh air etc.?)
        Appetite & thirst: (what foods/drinks/flavours/condiments etc. do you either crave or have a strong dislike of? does any food or drink cause an adverse reaction? how thirsty are you?)
        Blood Group
        Fears or phobias: (For example - heights, closed spaces, dark, germs, ghosts, animals, insects, snakes, spiders, storms, examinations, disease, poverty, failure etc.)
        Dreams: (Any dreams that stay in your memory. Any recurring dreams. Include childhood dreams. Please try to recall at least one dream that you have had in your life.)
        Any other health problems including life traumas, griefs, shocks etc.
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