Patient questionnaire (adult female)

Where did you hear about Bury Homeopaths?

Full Name *

Address: *

Postcode: *

GP’s Surgery: *

Age and Date of Birth: *

Weight and Height:

Occupation:

Contact Number: *

Email: *

Please state the main reasons for seeking homeopathic/naturopathic treatment (list as a timeline, i.e. your health concerns in chronological order, with the age when you first noticed symptoms & what they’ve been treated with below): *

Details of current medications, vitamin or herbal supplements and reasons for taking (brand, duration & dosage):

Details of previous medication & the reasons for taking it:

Any significant emotional traumas, e.g. loss of loved one, accident, divorce

Have you ever had any of the following? Where applicable, state your approx. age you had it and whether it was normal (n) or severe (s)

Measles, Mumps:

Sinusitis:

Glandular fever/mononucleosis or ME:

Auto-Immune Condition:

Tonsillitis

Recurrent Colds/Flu/Chest Infections:

Lyme Disease:

Ear Problems:

Asthma

Eczema, Dermatitis:

Any other conditions not listed?

Do you have regular headaches/migraines and how are they triggered?

If antibiotics taken in the past, please state approx date(s) and reason(s) for taking:

Do you, or have you smoked?

Smoke

Never Smoked

Previously smoked

Please list vaccinations and approx. age if known:

Covid Vaccines

If any, which Covid vaccines have you had (e.g. AstraZeneca, Pfizer, Moderna) and when?

Any reactions or new health concerns (immediately or after 3+ months)?

Menstrual cycle/history

Do you have periods? Please state the cycle length and duration:

Do you get any PMT symptoms? Please state what they are:

Do you have an irregular cycle? Please state whether it could be due to contraceptives, menopause, pregnancy or surgery:

Menopause

Do you have any menopausal symptoms? When did they start & what are they?

Children

If you have children, please state their ages and any significant issues during pregnancy or post birth:

Blood Tests

Any deficiencies identified or suspected?

If bloods taken within the past 18 months, please obtain a print out from your GP & bring along.

Diet and Digestive Issues

Please enter any diet info e.g. vegan, vegetarian, meat or fish

Do you ever suffer from: Heartburn, IBS, Crohns, Diverticulitis, constipation, diarrhea or just an uncomfortable digestive system?

Details of any operations, accidents, serious illnesses, or hospitalisation:

Please provide details of close relatives’ health status/illnesses if known:

Father:

Mother:

Brothers and Sisters:

Cancellation policy

Bury Homeopaths operate a 48-hour cancellation policy. If you cancel an appointment over 48-hours in advance, you will not be charged. If you cancel within 24 hours, you will still need to pay for the appointment in full. However, we recognise that emergencies happen and we will try to be accommodating in such circumstances.

Please Sign & Date

To sign this form, please enter your full name: *

Select today's date *

Bury Homeopaths keep all medical, patient information confidential and in a secure environment. Records will be kept for a maximum of 7 years from your last consultation date, as authorised by ANP, unless you request otherwise.

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Cancellation policy

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