Homeopathy New Patient Questionnaire

About This Form
This form helps me build a clear picture of your health and wellbeing. It usually takes around 5–10 minutes to complete. Please share as much as you feel comfortable and if anything feels unclear, unknown, or not relevant, it’s absolutely fine to leave it blank.

Name*

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Date of Birth — Helps offer care appropriate to your age and life experiences. If you’re under 16, parental consent is required. Feel free to get in touch if you’re unsure.*

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Email — Required for appointment confirmation and prescription delivery*

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Please fill in all the required fields.

Contact Number — Optional, but helpful if I need to reach you about your care or arrange delivery of your remedy

Address — This is needed so your prescription can be sent safely and directly to you.*

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Current Complaint, Symptoms & History — Please describe the main issue or concern that led you to seek treatment.*

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Symptom Details — Please share when your main symptoms began, how often they occur, what seems to ease or aggravate them, and anything else you feel might be relevant.

Allergies, Intolerances & Sensitivities — Please list any known allergies or sensitivities, how long you’ve had them, and how you manage them.

Vaccination & Immunisation History — You’re welcome to list as much as you can remember. (e.g. your age or year they were given, and any known complications or reactions).

Medical History — Please list significant illnesses, accidents, operations, or major events — along with your age at the time, how long they lasted, any treatment received, and the outcome if known.

Current Medication, Remedies & Supplements — Please list anything you’re currently taking, including the name, dosage, how long you’ve been using it, and the reason.

1. Mood & Temperament — How would you describe your overall mood and temperament? (e.g. calm, anxious, low, neutral, changeable)

2. Stress Levels — How would you rate your current stress levels? (Low, Moderate, High)

3. Recent Life Events or Changes — Have there been any significant life events or changes recently? (e.g. loss, relocation, relationship shifts, work stress)

4. Fears or Phobias — Do you experience any fears or phobias?(e.g. enclosed spaces, illness or medical settings, social situations, dogs, heights etc.)

5. Emotional Supports — What tends to support you emotionally? (e.g. time alone, being with others, music, nature)

Pregnancy — Are you currently pregnant or planning a pregnancy?

Menstrual Cycle — Please describe your menstrual cycle — for example: regular, irregular, heavy, light, painful, perimenopausal, or post-menopausal.

Family History Mother’s Side — please list any serious illnesses or conditions — such as addiction, cancer, epilepsy, diabetes, autoimmune disorders, heart disease, or other significant concern

Family History Father’s Side — please list any serious illnesses or conditions — such as addiction, cancer, epilepsy, diabetes, autoimmune disorders, heart disease, or other significant concern

Anything Else? There’s no expectation to write anything here — it’s simply a space if you’d like to add more

Consent to Treatment, I understand that I have requested a homeopathic consultation and may ask questions or pause treatment at any time. Decisions about prescribed medication remain my responsibility*

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By submitting, you consent to your details being stored securely and used to respond to your message, in line with GDPR. All information is treated as confidential and never shared without consent. You can request to update or remove your information at any time*

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