Questionnaire for homeopathic treatment
This questionnaire is an important aid in your treatment. Accurate and detailed answers are essential in order to yield an exact picture of your health condition.
All questions are therefore applicable, and are to be answered honestly and without reservation. Particularly important are those questions referring to psychological health.
The conscientious physician considers the most minute subtleties of disease expression. There are a multitude of feelings, symptoms, modalities and external triggers that accompany a disease. It is these seemingly irrelevant symptoms and completely individualized impressions that accompany and could prove most critical in identifying characteristics of a certain state: “can hardly breathe in a warm room”, or “symptoms ameliorated with heat”, or “it feels like a hair on my tongue”, etc. Consider these ideas with every question, and illustrate your points with exactness and detail (use a separate sheet when more room is needed).
1. Abnormal mind and mental symptoms:
For example “the feeling of being pursued” or “fear of uncertainty/loss of control”.
That is, which influences improve or aggravate a condition (for example, improvement or aggravation with heat, cold weather, rest, movement, during meals, before or during menses, certain time, during a particular routine, atmospheric condition, etc.)
3. Feelings/ Sensation:
For example: pulsating, stinging, radiating pain in which region, with extension to where). Do not repeat terms used by a physician to describe your symptoms, just report spontaneously. Try to find as exact an expression as possible in order to describe your feelings and You may add observations from Your environment. In case your complaints are peculiar, you may use comparisons like: “cold in the area between the shoulder-blades, as if water was squirted on it”, or “pain in the heart, as if a hand is gripping it ”. With long-standing, established (chronic) disease details are of utmost importance, even former complaints. Symptoms like: night sweat, gland swelling, loss of appetite, thirst, abdominal pain, indigestion, aversion or desire for certain food (e.g.milk, fat, fruits), strange desires (eat chalk, lick salt), periodical complaints, character of discharge from nose, ears, throat, vagina and penis should be mentioned, as well as their individual details (Quantity, appearance, color, smell, a corrosive character).
When answering the questions below, use the following procedure: Use typed or block letters. Skip to the “Special Questions” section. Scan to where you find the organ or region which is the source of your complaints, then answer all relevant questions in detail. Do not forget, in the likely event you need to use a separate page to detail your answers, and refer to the number of question you are answering. After completing all relevant “Special Questions”, go to the “Modalities” section, and detail all outside influences which either improve or aggravate your condition – this needs to be done for each organ or region causing symptoms. Finally, answer questions found in the “General Questions” section including psychological symptoms, and include all noteworthy or peculiar observations.
1. Detail diseases and important characteristics of your parents, grandparents, the whole of Your family. Name the diseases and main complaints shortly. How old were they when that disease or death occurred?
2. How long have you had your disease or complaints? When, how and where did it emerge? Was anything important happen at that time? Identify external and internal circumstances that were present or may have played a role for that disease or condition. (sickness, cold, heat, draft, humidity, draught, fog, grief, rage, annoyance, injuries, food incompatibilities)?
3. Is your complaint limited to specific organs, or do you have specific complaints that extend throughout your body? How so? For example: feeling of crawling/tickling, emptiness, feeling of weakness, tingling feeling of numbness, oppression, specific anxieties, feeling of constriction? Name the exact location in Your body? Identify how complaints are caused, aggravated or improved?
4. Which is the time of day or night, or the circumstances under which these complaints are sarting, aggravated, improved or ameliorated (f.e.meals, cold weather, heat, excitment, occupations, routine etc.)?
5. Do you have to dress warmly or wrap certain parts of Your body to feel well normally or in order to reduce suffering?
6. Detail the exact character of the complaint. Do you have pain or a certain sensation(burning, bounding, oppressive, stinging, paroxysmal, restlessness. Or provide your perception of the disturbance: feeling of swelling, feeling of heaviness, as of a stone or a block).
7. Is it a constant complaint, or do you have trouble-free periods?
8. Can you note seasons or periods within a month or the year in which the complaint is aggravated?
9. At which time of the day or the night is the complaint most frequent appearing or especially strong/painful?
10. Name any special circumstances or influences, which aggravate or improve your complaint?
11. Describe the condition or the appearance of the concerned part of the body, the extension, sensitivity, temperature, color, dryness, moistness, or discharge.
12. Describe the constitution of your discharges (from eyes, ears, nose, vagina, penis, etc.). Include quantity, color, smell, condition ( milky, slimy, creamy, thready, sticky), their composition (containing blood, crusts, skin, pus etc.), and whether discharges are corrosive, pungent, or cause damage or discoloration to the environment.
13. Which are other complaints you suffer from most often (constipation, diarrhea, insomnia, cold or heat sensitivity, food indigestion)?
14. List all the diseases or important events You have gone through since your birth in tabular form (like anginas, otitis, frequent bronchial respiratory inflammation, stomach, grief)? (write the table on a separate paper
How old were you when you took your first steps?
How old were you when you spoke your first words?
15. List medication(s) you took previously (also homeopathic), frequently or regularly or taking at the moment?
16. Which is the occupation that tires you the most (mental or physical effort)?
17. Do you experience sleepiness after meals? Or certain time in the day when Your energy is dropping? Do you feel better motion?
18. Detail any complaints you experience during rest or sleep(heart palpitation, pressure on the heart, headache etc.) When exactly?
MODALITIES (see preface): You should carefully think about the circumstances that cause any change of Your condition – whether it is to improve, aggravate or to eliminate symptoms. Record in this section those circumstances that have an influence on the general condition or just on certain symptoms.
19. How are You influenced by: Change of weather, cold weather, warmth, humidity, thunderstorms, rain, fresh air, fog etc.?
20. What symptoms do you experience during different phases of the moon?
21. How does the following influence you: Odors, noises, music, the spoken word, sunlight or artificial light, darkness, twilight, night, company, solitude, meals (during and afterwards), fasting or hunger, standing or lying (on the back, on the side etc.), motion like walking or moving certain parts of Your body, touch, pressure, rubbing, a hot or cold bath, in closed places, warm rooms, close to the water or the sea, in the mountains?
Mind and mental symptoms:
22. Characterize your temperament: you are gentle, attached, detached, sentimental, prone to anger, prone to crying, melancholy, sad, violent, passionate, You like or dislike consolation?
23. To which of the following are you most sensitive: Reproach, injustice, grief, slander, or contradiction?
24. How do you react when confronted by influences described in question number 23? (tears, open or secret anger, depression, you retreat into your room, etc.)?
25. Are you independent, reliable, easily influenced/impressionable, stubborn or weak-willed, tyrannical or flexible?
26. Are you indifferent, and if so to whom and since when, always or only since your disease (to your family, spouse, or to friends).
27. Are you brave, shy, anxious, stout-hearted, or despairing?
28. Do you have understanding and patience? Are you perceived in the community as pleasant, or are you controlling or intolerant of contradictions.
29. Do you like to bath or wash Yourself with pleasure or are you careless in this respect? How were you in this respect as a child?
30. Is your temperament very exact, almost fastidious or careless: in your occupation, in your private room, your desk, and your clothing.
31. How were you at school? Did you have self-confidence, or shyness and hate the spotlight? Were you keenly observant of school rules, or indifferent? Are You sensitive for critic and how do You react?
32. How do you behave in public? Do you love conversation, to be a lecturer? Do you take others’ interests into consideration when engaging in conversation, or you rely mostly on Yourself?
33. Do you have calmness or are you impulsive and quick to react?
34. What are your characteristic traits: jealous, greedy, wasteful, rigid, stubborn, tend to contradict?
35. Do you enjoy a calm and predictable life or do you prefer flexibility and change?
36. How are you affected by changes, travel, or Your regular daily life?
37. What is your usual mood (content, happy, joyful, optimistic or
pessimistic, irritable, negative thoughts)?
38. Are you subject to quick mood changes? When, caused by what?
39. How do you react to injustices in your life or done to others, even strangers (quietly, crying, quiet grief, obvious rage, with violence or coarse words, You would enter a discussion even in a big group)?
40. Has your character changed through the years? If yes, in which respact?
41. Do you believe you suffer from inner conflicts?
42. How are your intellectual capabilities (intellectual energy, memory, ability to concentrate, ability to work)?
43. Do you experience vertigo, a loss of feeling or awareness?
(Describe the sensation as exact as possible for example:
“from or to one side”, vertigo when lying, when moving, when standing, when eyes are closed or open, when turning the head, when bending, when looking up or looking down, after eating, sensation of falling forward or backward)
44. Do you suffer from headache? Describe the exact location of this headache and its character? How long as the headache existed? When does the headache appear?
45. Is your headache aggravated during the day or at night? When is your headache more severe and at what times does it stop? What influences your headache like: rest, movement, pressure, position of the head, covering the head, cold weather, heat, fresh air, full or empty stomach, in the time before, during or after your menses?
46. Which circumstances accompany, precede, or follow your headache: (impaired vision, nausea, vomiting, hot flushes, chills etc.)?
47. Describe your hair (color, growth properties, density, smooth or curly, hair loss – localized or diffuse since when?)
48. Describe your eyes (lachrymation, inflammation of the eyes or edges of lid, styes, discharge, dryness, incrustation, loss of eye-lashes).Where and since when? Do you suffer from Photophobia?
49. Are you near- or far-sighted? Are you able to wink? Squint? Does eye pain exist? (f.e. “pain, as if the eyes were pulled into the head, feeling as if falling out of the head”, “feeling like sand in eyes”).
50. Describe with in detail if and how Your vision is impaired. always or at certain times? Which circumstances amel. or aggravates it (season, temperature, reading, light, etc)?
51. Do you have ear pain, loss of hearing or suffer from tinnitus? Do you have trouble hearing all sounds or only the spoken word? Do you hear noises like humming, wheezing, knocking, when?
52. Describe your nose: Do you have inflammation, crusts, abscesses, itching, clogging, hemorrhage, chronic discharge, coryza, congestion, hay fever, pain in the sinuses?
53. Do you have a stuffed nose, only on one side, occasionally or always? Do you have disturbances of smelling, or are You sensitive to smells and if yes, which ones?
54. Describe the skin of your face, ears, nose, and head.
55. Do you have eruptions of the skin in the face, warts, dryness, redness or cracks (of lips, corner of the mouth, eyes, nostrils)? Perspiration and where (Please describe the appearance exactly)
MOUTH, NECK, TEETH:
56. Describe the condition of your lips, tongue, tonsils teeth, the gums (dryness, salivation, odor from the mouth, fissures, wounds). Do you often blister at the lips? Aphthae?
57. Do you perceive a unique pain or sensation while chewing or swallowing? (Is it worse with swallows of pure saliva, or when swallowing foods and drinks?)
58. Do you experience burning on tongue? At the tip or at the edges? Can you freely move the tongue, are there any sensations such as tingling, paralysis, swelling, sensation of numbness)?
59. Do you have any taste abnormalities like: everything tastes bitter, metallic, like rotten eggs, salty, sweet? Do You have salivation in the night or in the daytime
60. How is the condition of your teeth? Are they strong, healthy and complete, or do You have problems caries? Any discoloration (yellowish, brownish, blackish)? Any pains, or other feelings( as if too long or too loose)? What amel. Or aggravates the teeth complaints. (Hot or cold liquids, pressure, menses? Were or are You grinding or clenching teeth.
61. How is your appetite? Do you have urgent hunger? When and for what? Are you quickly satied and do have appetite quickly after finishing to eat?
62. Do you have aversion or disgust against any food (like fat, eggs, meat, sweets, sour foods, milk, alcohol, coffee) or cooking smells?
63. Have extraordinary craving for certain foods (sweet, salty, sour, smoked meat, bread, fruit) or for certain beverages (cold water, hot milk, beer, wine, liquor)? Do cravings exist despite stomach incompatibilities (Please answer spontaneously)
64. Do you have thirst and for which beverages? (In large or small quantities, hot or cold, during the day or at night)
65. Which problems appear after the meal or drink, and after which period? Do you feel better or worse after drinking, eating food or when the stomach is empty? Any sensations connected to your stomach?
66. After eating which food do you feel worse (milk, bread, meat, acids, potatoes, alcohol, fats, sweets, ice or fruit)?
67. Do you have any burning (at tongue, throat, stomach, anus, etc.)? Vomit, nausea or stomach pain? What are the times of day and circumstances which evoke it or aggravate, diminish it?
68. Which other complaints precede or follow them? Do you feel better or worse after burping, passing gas, or vomiting?
69. What is the appearance, the taste, the color, and the smell of your vomit?
BELLY AND INTESTINES [?]
70. Do you have gas, flatulence, and on what occasions? At what time of day? After eating? After which kind of food ?
71. How does your gas smell, and do you feel relief after outlet, the same, or no difference?
72. Where in your stomach is your pain? How does it react to pressure or friction? To the application of heat or cold?
73. How do you react/behave when you have a stomach ache? Do you curl into a fetal position or do you press your stomach against the back of the chair or can you not stand to touch the area?
74. When you have pain, do you loosen your clothing, particularly belt, collar, suspenders, corset, etc. to ease discomfort?
75. How often daily do you have bowel movements? Explain the condition of the stools (thickness, color, smell, quantity, consistency, mixed with slime or blood)?
76. Do you have a tendency to get diarrhea? Describe the type of diarrhea: is it slimy or like water? Does it come in a wave, all at one time, or little-by-little? Does it come early in the morning or immediately after eating?
77. Do you have bowel movements at regular times of the day, morning or night? Do they drive you out of bed, or do they occur after you start moving etc. Following a bowel movement, do you still feel a urge or get the feeling you are not finished, or get cramp-like pain in/around your anus? Do you get generally a lot of gas? Do you experience cutting pain, rumbling and when? Do you feel as though you have a ball in your anus?
78. Does your anus itch, do you have hemorrhoids, experience local sweating or any pain at the anus. History of fistula? Eruption, Warts?
79. Do you have pain in your bladder, your urethra? Does your urine flow well, immediately and without impairment?
80. How often and how much do you urinate? Describe the color and the smell of the urine. Is the urine clear or cloudy? (white, milky, brick-red, or dark brown)? How strong is the urine stream – is it forked? Does your urine flow only in certain positions?
81. Do you void urine involuntarily when coughing, sneezing, laughing, standing, moving, lifting, lying, during the day or at night?
82. Frequent urge to urinate exist, during the day or at night? Drop by drop, with or without burning, stinging, or cramping?
83. Does an urge to empty large quantities of clear-colored urine exist, before or after excitements, by anticipation, fright or pain?
84. Does your urine have a strange odor (like violet, cat urine, horse urine, harsh, abrasive like ammonia, obtrusive, or putrid)
85. Do you experience peculiar sensations in the urethra, during or after urination? Do you experience pressure to urinate at the sight or sound of running water? Difficult to urinate in the presence of others?
86. Is your sexual desire normal, increased, or diminished? Do you engage in regular sexual activity, or is your ability impaired by certain circumstances?
87. Do you have any pain or other disturbing sensations in or at the sexual organs?
88. Do you feel a normal degree of satisfaction during and after the climax? Do you feel particularly tired or deteriorated after climaxing? (heart flutters, cross (back and shoulder) pain, exhaustion, vertigo, sweating, nausea, soreness) – do you get these sensations before during or after menses?
89. Do you experience strange inclinations, needs or desires in your erotic relationship, masturbation , unfaithfulness to partners, do you think only of yourself during sex or also about your partner)?
90. Did you have a sexual transmitted disease? Condylomata? Please specify which one, when, and how you were treated.
91. Do you experience erections and ejaculations that are normal, premature, retarded, or occur in sleep?
92. Do you have any problems with your testicles (pressure-sensitivities, pulling or squeezing, expansion of the veins, itching of the testicles, perspiration, swelling, hardening, ulcers)?
93. At which age did you get your first menstrual period?
94. Since what age did your period stop?
106. Do you have any trouble with respiration? Are you short-breathed when resting or during movement? Do you feel constriction or pain in your thorax and/or bronchial tube, or feelings of anxiety?
107. How is the condition of your voice? Are you repeatedly hoarse? When (exposure to cold drafts of air, excitement, extended talking)?
108. Do you have mucus (easily soluble; tough; contains small lumps, large masses, or long threads; tastes salty, sweet, foul or is it tasteless)?
109. Are you coughing? Describe your cough (frequency, strength, dry or productive, rattling, barking or suffocative)?
110. When do you cough (which hour of the day and/or night, at rest or with motion, in the warm room or in the open air, when laying down or standing up, while eating or while drinking, after inhaling cold air, at night getting warm in bed, after you first wake from sleep, at midnight, after midnight, or after other external influences)?
111. What calms your cough down? (calming influences such as: sipping hot drinks, covering mouth, moving around, open air)
112. What are the side effects, preceding or following coughing (chest pain , belly ache, headache, burning, body covered in cold sweat, followed by chills or accompanied by involuntary urination)?
Trunk and limbs:
113. Do you experience heart palpitations? The feeling of pounding or irregular heart? Feeling as if an iron hand was gripping your heart? Do you experience anxiety that your heart will stop, when moving or standing still? (Describe all modalities that influence the complaints: rest, movement, effort, excitement, menses, weather changes.)
114. Does tight clothing make you feel uncomfortable, and are you in the habit of loosening the clothing (belt, collar)? At what time of day?
115. Do you have pain in your back, between your shoulder-blades, in the kidney, pelvis or sacrum area? (Standing, moving, bending etc.?)
116. Do you have pain in your muscles, your bones or in your joints?
117. Is the pain constant, is it only a single part of the body, or does it wander? Which side of the body suffers predominantly from pain?
118. In which direction does the pain go? Ascending or descending, do you experience the pain only on one side or does it cross the body?
119. Describe circumstances and times that cause, aggravates or improves the pain (daytime or nighttime, standing, lying down, beginning of movement, continued motion, or after movement, while traveling, with cold or warm application, changes of weather, etc)?
120. Is the skin above hot or cold, swollen, are the involved joints swollen, sensitive or does pain improve with pressure?
121. Do you have swelling of joints, weakness or cracking and where?
122. Do you suffer from cold feet and cold hands? Any bluish discoloration or a feeling of heat f.e. in the soles of your feet?
123. Do your arms get numb overnight or a feeling of enlargement or swelling, especially the fingers? When are these symptoms worse, before or after midnight, with cold or warm, weather change?
124. Do you suffer from cramps in your calves or feet?
125. Do you have swollen glands (at the neck, in armpits, around the breast)?
126. Describe the swollen glands (large, small, hard, soft, hot, cold, red, painful or painless and since when)?
127. Do you have varicose veins in your legs, labia, abdomen, or other blood vessels (also at your cheeks, nose or other parts of your body)?
128. Have you experienced the dragging down of one or more organs, (uterus, stomach) ?
129. Do old scars exist or other similar physical defects? What sensations do you experience in those areas?
130. Do you have other physical complaints exist not mentioned here?
131. How is your sleep, at night or during day (deep, light, restless, refreshing, superficial, interrupted)?
132. At what time, day or night, do you need to sleep or get drowsy?
133. If you fall into a deep sleep, is the sleep interrupted, at which time, can you easily go back to sleep or are stay awake and how long?
134. Describe whether it is feelings or stark pain that disturbs your sleep. You wake from sleep or are prevented from sleep ( thoughts, dreams, twitching, pain, restless legs, nightmares, headache, thirst)?
135. Describe the most pleasant rest position for you, as well as which position is especially disturbing (right, left, back, belly, flat or raised)?
136. Describe your dreams, mainly those which wake You up, whether you can remember, whether dreams are recurring.
137. Do you make involuntary movements during sleep (twitching limbs, talking, screaming, teeth grinding, restless tossing about)?
138. Are you refreshed after a long or short sleep?
139. Do you get colds easily?
140. Do you suffer from specific chills, and describe where. Are they restricted to a specific region of your body ?
141. Are you sensitive to cold or quickly get overheated, or You are sensitive to both extremes?
142.Do get high fever, when was the last one?
143. Do you have a tendency to feel feverish? In your feverish state, are you thirsty or not? Does your skin stay dry or sweats easily?
144. Do you experience hot flashes and in which parts of the body, with or without sweat and at what time, day or night?
145. Do You experience restlessness in your body? What aggravates them (menopause, before menses, after a meal, warm room, in bed)?
146. Does your body perspires easily? Where? ( neck, on the scalp, forehead, upper lip, face, armpits, hands or feet, genitals, only on one side, when eating?)
147. What is the quantity of your sweat, its smell, its color, its quality (sticky, cold or warm, offensive, sour, like garlic, stains the linen)?
148. How are Your complaints altered by perspiration?
149. What is the condition of your skin (dry, moist, firm, describe color, oily or scaly, blushes easily)?
150. On which parts of the body are eruptions, acne, ulcers, outgrowths, boils, freckles, warts, abscesses and since when?
151. Describe their condition, color, form, firmness, sensitivity, appearance and expansion.
152. What do you perceive at the affected body part, and what are the circumstances and time of the day, night, or year that aggravates, improves the condition? (itching, burning, heat, stinging, affected by shivering, cold weather, pain, tension, swelling, etc.)
153. Describe discolorations or eruptions on Your skin, how they look (color, smell, corrosive effect, quality of discharge)?
154. Did you suffer in your past from a skin eruption? (Childhood, teenage or adult age, acne pustules on back or face, rush, eczema, shingles, frostbites?)
155. How do your fingernails and toenails look (color, thickness, form, defectiveness in growth, speed of growth, they are fragile, spotted?
156. Do you have tears or fissures in nails or nailbeds, ingrown nails?
157. Does your skin tend to callus, especially at places that experience constant pressure? Do the calluses crack and develop inflammations?
158. Are your lower thighs, especially in their lower third, discolored red, violet, brownish, or blue-brown? In there an inclination for ulcers, swelling, stinging heat, shivering, intolerance of warmth in bed? Do you have discolored skin at the ends of your toes, and describe it.