New Homoeopathy Patient Questionnaire

Name(required)

Date of Birth(required)

Address(required)

Postcode(required)

Telephone number(required)

Email(required)

GP's Name(required)

GP’s Surgery Address(required)

GP’s Surgery Tel(required)

Please explain briefly why you are seeking homoeopathy(required)

Are you taking any medication currently e.g. prescription medication, vitamins, food supplements, herbal remedies, aspirin, contraceptive pill, HRT, etc.?(required)

Please provide as much detail about your family medical history as possible (siblings, parents, grandparents, aunts, uncles) e.g. alcoholism, mental health issues, arthritis, tuberculosis, cancer, heart disease, diabetes, etc(required)

Please list all childhood diseases, age at the time and whether mild or severe e.g. measles, chicken pox, mumps, glandular fever, whopping cough, tonsillitis, diphtheria, ear problems, recurrent colds etc. (required)

Do you suffer from any allergies e.g. drugs, pollen, animals, foods? Please provide details.(required)

Please provide brief details, including month/year, of any surgical procedures, accidents, serious illnesses, or hospitalisation:(required)

Please provide details of any environment and weather preference/reaction e.g. cold, hot, sun, wind, mountains, sea, forests, thunderstorms, etc(required)

Please provide details of any food or drink cravings or dislikes e.g. chocolate, cold milk, hot drinks, salt, vinegar, etc(required)

Please provide details of any fears or phobias e.g. snakes, spiders, the dark, heights, dentist, etc(required)

Please provide details of any recurring dreams(required)

Please take care when filling in this questionnaire and check the contents are accurate before you submit it. By submitting this questionnaire, you are confirming that the contents are true and accurate to the best of your knowledge. Please notify Aura Homoeopathy of any changes to your responses in this healthcare questionnaire before commencing homoeopathic treatment. Please check all of the following boxes to confirm that you have read them:(required)

I hereby consent for Aura Homoeopathy to store and use my data to analyse the conditions for which I have consulted you and to prescribe remedies and other therapies. I agree for Aura Homoeopathy to add to this initial information with details of subsequent consultations I undertake with you. In line with current data legislation I agree for you to keep this information for as long as I continue to be a patient of Aura Homoeopathy. I agree for Aura Homoeopathy to keep my information for 7 years after my last consultation and in the case of children 7 years after their 18th birthday. I agree to inform you of any changes I believe should be made to the personal information Aura Homoeopathy holds.

I agree for you to communicate with me by:(required)

Email Other digital methods Telephone Post

Please re-type your full name below to confirm your consent(required)