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FOR A MORE PRECISE PRESCRIPTION PLEASE FILL OUT ALL THREE FORMS

For A Homeopathic Consultation

 

 

 

 

FEE INCLUDES THREE COMMUNICATIONS BACK FORTH

BEGIN CONSULTATION
NAME
AGE
CHIEF COMPLAINT:
HOW LONG HAVE YOU HAD IT?
HOW DID IT START?
WHAT DO YOU THINK CAUSED IT?
HAVE YOU HAD THIS BEFORE?
IF SO WHEN?
HOW OFTEN?
HAVE YOU HAD MEDICAL ADVICE?
WHAT WAS YOUR TREATMENT?
WHAT MAKES IT BETTER OR WORSE?
CAN YOU DESCRIBE THE PROBLEM?
WHERE EXACTLY IS THE PROBLEM?
HEAD
EYES
EARS
NOSE
MOUTH
THROAT
STOMACH
ABDOMEN
BOWELS
URINATION
NECK
GLANDS
BACK
ARMS
LEGS
SLEEP
HOW DO YOU FEEL GENERALLY?
YOUR COMMON ENERGY LEVEL?
MOOD
DEPRESSED?
IRRITABLE?
ANGRY?
ANXIETY?
FEARFUL?
EXCITABLE?
DESPAIR?
AFFECTIONATE?
WHINY?
ANY OTHERS?
DULL?
CONFUSED?
CONCENTRATION?
OVERACTIVE MIND?
IS MEMORY AFFECTED?
ANY OTHERS?
HAVE YOU MOVED RECENTLY?
CHANGED YOUR JOB?
SUFFERED TRAUMA MENTAL OR PHYSICAL?
DESCRIBE ANY CHILDHOOD PROBLEMS:
DESCRIBE ANY EVENTS YOU ARE DISSATISFIED WITH:
MOVING?
JOB?
MARRIAGE?
FAMILY?
RELATIONSHIPS?
ARE ANY OF THE ABOVE PROBLEMS CHRONIC?
PLEASE ADD ANYTHING NOT COVERED YOU WOULD LIKE TO MENTION?
RETURN EMAIL HERE                                                  
  

 

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FOR A MORE THOROUGH REPORT PLEASE SUBMIT THE NEXT FORM

PLEASE CHECK YES FOR ALL THAT APPLY

 

To ensure proper service please enter your e-mail address in each form.

1. Do you have vague fears which you can't explain?

 

YES
2. Do you often find yourself distressed and anxious, but are unable to put your finger on the problem?

 

YES
3. Do you wake with a sense of apprehension and foreboding, feeling that something bad may happen, but don't know what it may be?

 

YES
4. Do you have specific fears you can identify and would like to overcome?

 

YES
5. Are you shy and easily frightened by particular circumstances and things?

 

YES
6. When faced with situations or things that frighten you, do you become nervous and too paralyzed to act?

 

YES
7. Do you fear losing control of your mind or body?

 

YES
8. Are you compulsive, or have impulses to do things you know are wrong but have difficulty controlling your actions?

 

YES
9. Do you fear losing control and hurting yourself or others?

 

YES
10. Do you worry over the health and safety of your friends and family?

 

YES
11. Do you fear that something may happen to those close to you?

 

YES
12. Does your over-concern and worry for others cause you considerable distress?

 

YES
13. Do you suffer from extreme terror?

 

YES
14. Do you tend to panic and become hysterical?

 

YES
15. Are you troubled by nightmares?

 

YES
16. Do you lack confidence in your ability to judge things on your own and make decisions?

 

YES
17. Do you find yourself asking peoples advice, even when you know what you want?

 

YES
18. After taking advice from others, do you find yourself confused by the choices, constantly changing direction with each recommendation?

 

YES
19. Do you suffer from indecision, uncertainty or hesitancy?

 

YES
20. Do you have difficulty choosing between one thing and another?

 

YES
21. Do you experience extreme mood swings, or have difficulty in keeping your balance?

 

YES
22. Are dissatisfied with your current role in life, feeling that life is passing you by?

 

YES
23. Have you tried many different directions in life, but nothing seems to bring satisfaction?

 

YES
24. Would you like to find a new lifestyle or career, or change your old one, but having difficulty deciding what you should be doing?

 

YES
25. Do you lack confidence?

 

YES
26. Do you not try things for fear of failing?

 

YES
27. Do you feel inferior, and that others are more capable and qualified than you?

 

YES
28. On rising do you find yourself tired, not wanting to get up?

 

YES
29. Do you feel some part of you needs to be strengthened before you can tackle the day?

 

YES
30. Do you find once you started your daily activities your tiredness is forgotten, and you are able to complete your task?

 

YES
31. Are you absent minded, or does your attention easily wander, making it difficult to concentrate?

 

YES
32. Do you find you have little interest in present circumstances, often day dreaming, wishing you were somewhere else?

 

YES
33. Do you find yourself dozing off frequently, regardless of were you are?

 

YES
34. Do you find yourself caught between living in the present and dwelling in memories of the past?

 

YES
35. Are there things you would like to have done with your life but never had the opportunity to do?

 

YES
36. Do you find yourself reminiscing about the good old days, whishing you were able to live your life over again?

 

YES
37. Do you find yourself indifferent and apathetic toward life?

 

YES
38. Are you resigned to your current circumstances, making little effort to improve things or find joy?

 

YES
39. Do you feel you have given up and don't care one way or the other what happens?

 

YES
40. Are you troubled by persistent unwanted thoughts?

 

YES
41. Do you worry or have mental arguments that circle around in your mind?

 

YES
42. Do you have difficulty sleeping due to mental chatter and worries?

 

YES
43. Do you find you are unable to learn from past experiences, repeating the same mistakes or patterns of behavior?

 

YES
44. Due to lack of observation, do you find it necessary to go over or correct things already done?

 

YES
45. Is there a particular situation or condition continually recurring in your life which you would like to overcome?

 

YES
46. Are you now going through, or have you recently gone through, an illness or personal ordeal that left you physically and mentally drained?

 

YES
47. Do you tire easily with no reserve energy to complete your tasks or enjoy the day?

 

YES
48. Do you feel sapped of strength and vitality, where even the least effort exhausts you?

 

YES
49. Do others find you aloof, prideful and at times condescending?

 

YES
50. Do you keep to yourself, not wishing to be interfered with or to interfere in other peoples affairs?

 

YES
51. Are you self reliant and prefer spending your time alone?

 

YES
52. Do you find losing patience, becoming tense and irritable with people and things that move too slowly for you?

 

YES
53. do you do things in a rush, racing from one place or situation to another?

 

YES
54. Do you find you need to work alone, because others can't keep up with your pace?

 

YES
55. Do you find others avoiding conversation with you because you tend to talk a great deal?

 

YES
56. Do you dislike being alone and seek the company of anyone willing to listen to your troubles?

 

YES
57. Do you feel the need to steer conversation back to your special interests or problems, and are reluctant to discontinue them even when the listener has to leave?

 

YES
58. When worried or in pained you tend to conceal it from others, making light of eventhe most trying of circumstances?

 

YES
59. Do you go out of your way to avoid burdening others with your problems, or giving in to others' wishes in order to aviod an argument or quarrel?

 

YES
60. When troubled, do you find yourself drinking alcohol or using drugs to assist in keeping up a happy disposition?

 

YES
61. Are you easily imposed on because of your willingness to help others?

 

YES
62. Is it difficult for you to say no when you are asked for help, becoming more a servant than a willing helper?

 

YES
63. Do you neglect your own needs, because you are busy taking care of other people's needs?

 

YES
64. Are you invovled in a relationship or situation that you would like to be free of but can't break away from?

 

YES
65. Are currently in a state of transition or change?

 

YES
66. In the midst of this change, do you find your having difficulty letting go of the past attachments and starting new beginings?

 

YES
67. Are you suspicious and mistrusting of other people's motives and intentions?

 

YES
68. Do others find you spiteful, envious, jealous or vengeful?

 

YES
69. Do you find yourself lacking compassion or warmth toward others?

 

YES
70. Are you rarely content with your accomplishments, feeling that you could always do better?

 

YES
71. Do you blame yourself for other people's mistakes, feeling that their shortcomings are in some way your fault or responsibility?

 

YES
72. Are you hard on yourself when you fail to live up to the standards or expectations that you've set for yourself?

 

YES
73. Do you tend to over extend your commitments?

 

YES
74. Do you find yourself overwhelmed by your work and despite being capable, feel you've taken on more than you can do?

 

YES
75. Do you become despondent when faced with the magnitude of your responsibilities?

 

YES
76. Have there been past traumas or shocks in your life which you may not have completely recovered from?

 

YES
77. Have you ever suffered a personal loss which you have not gotten over?

 

YES
78. Do you feel past surgery or accident is responsible for your present condition?

 

YES
79. Do you feel you have reached the limits of your endurance, and there is nothing but annihilation left to face?

 

YES
80. Do you suffer from mental anguish and deep despair?

 

YES
81. Do you feel that the burden of life is more than you can bear?

 

YES
82. Have you lost hope that you will recover from, or be helped in overcoming, an illness or difficulty?

 

YES
83. Do you feel it is useless to seek further help for your problems?

 

YES
84. Have you given up hope that things will change for the better in some circumstances or situation in your life?
 
YES
85. Do you ever become gloomy and depressed for no known reason?
YES
86. Does this depression envelope you like a dark cloud, hiding the joy of life?

 

YES
87. Do you find this gloom and depression, for no apparent reason, lifts as suddenly as it comes?

 

YES
88. Are you easily discouraged when things do not go your way?

 

YES
89. When setting out to accomplish a task, do you become oversensitive to small delays and hindrances which may lead to self doubt at times of depression?

 

YES
90. Is it hard for you to start over again once you've encountered difficulties?

 

YES
91. Are you one who tirelessly struggles on despite opposition and delays?

 

YES
92. Can you always be depended on to complete what you set out to do, regardless of the challenge?

 

YES
93. Do you tend to throw yourself into your projects, neglecting your own needs as well as the needs of those close to you?

 

YES
94. Through no fault of your own, do you feel that life has been unfair or unjust to you?

 

YES
95. Have you become resentful and bitter toward those who may have treated you poorly?

 

YES
96. Despite all you have done, do you feel your best efforts have largely gone unrewarded, while others not as deserving as yourself have gained?

 

YES
97. Do you feel unclean or ashamed over an act you should not have committed, or over someone or something having violated you personally?

 

YES
98. Do you find yourself preoccupied with small physical problems such as pimples, small blemishes or rashes, while overlooking more serious conditions?

 

YES
99. Do you feel there is something wrong with, or some things you would like changed in your physical appearance?

 

YES
100. Are you compulsive about cleanliness, even at times to the extreme?

 

YES
101. Are you afraid of becoming, or feel you've already become, contaminated and need to be cleansed?

 

YES
102. Are you possessive of those close to you and feel you know what is best for them, often directing and correcting even small details in their lives? 

 

YES
103. Do you feel you are not appreciated by those you care for?

 

YES
104. Do you find yourself needing the attention and devotion of those you love, feeling it's their duty to stay in close contact with you?

 

YES
105. When assessing people and situations, do you look for what you can find wrong?

 

YES
106. Do small habits and idiosyncrasies of others bother you?

 

YES
107. Are you critical and intolerant to those who do not measure up to your standards or expectations?

 

YES
108. Do you have strong opinions which you attempt to convince others are right?

 

YES
109. Are you easily incensed by injustices, arguing for and defending principles which you believe in?

 

YES
110. Are you high strung, at times tense and over enthusiastic, always teaching and philosophizing?

 

YES
111. Do you feel you have a mission in life to conform with or live up to?

 

YES
112. Are you strict in your adherence to a religious or social discipline, or toward a particular way of living?

 

YES
113. Do you feel it is important to make an example of yourself by living up to your ideals, so that others may follow?

 

YES
114. Do you tend to take charge in circumstances and situations you are involved with?

 

YES
115. Are you strong willed and expect complete obedience without question from those around you?

 

YES
116. Do you consider yourself a "born leader"?
 
YES
 

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MIND YOUR HEALTH

HOLISTIC THERAPY -  HOMEOPATHY

B"H

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DESIRE CONCEIVE IMAGINE INTEND DECIDE CREATE IMPLEMENT