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How to Report Symptoms to a
Homeopathic Physician

(Please type or write answers clearly on separate sheets of paper).

While homeopathy is not psychiatry per se, much of the information you provide about yourself will be critical in helping your homeopathic physician select the most suitable homeopathic medicine for you. You are also encouraged to be thorough, but brief. Focus on what is most important. Many of the details will be discussed during your interview. All of your responses will be kept in the strictest confidence. Your narrative should not exceed five typed pages (handwriting is fine if legible).

1. Describe the beginning and exact nature of your complaints (or those of your child, if the child is the patient). State just how they began as well as the changes that may have taken place since. State exactly how the complaints feel. Precisely describe in great detail the sensations of the complaints you feel in your body and mind, how these sensations affect your life, and, in what ways do you feel that they limit you.

2. Mention all previous illnesses. A complete history of your health is important, even of such things as skin diseases, children's diseases and their after-effects; tell of fevers, colds, flus, sores, ulcers, etc.; also injuries, if any. Tell their location and what treatment was used.

3. Tell, if you can, all therapies that have been used and your response.

4. Describe all mental or "nervous" feelings and conditions, such as likes and dislikes, desires, fears, timidity, hurried feelings, lack of interest, persistent thoughts, discouragements, discontent, over-conscientiousness, whether critical, irritable, easily confused, aversion to business or work, preoccupation with work or business, absentmindedness, changeable moods, difficulty of concentration, dullness of mind, whether easily startled or starting from sleep or when falling asleep, or from noise or being touched; whether annoyed by noise or talking of others or by children; whether easily affected by bad news or upsetting media (TV, movies, news); whether better or worse from mental exertion, or when occupied, whether sensitive to offense or contradiction; and, if your feelings are easily hurt.

5. Describe the state of mind as to the future or to threatening troubles; attitude of mind as to associates and relatives, and the effects of same, and whether better alone or with company. Tell the peculiarities of memory; whether there is a desire to be silent or to talk a lot. Tell of any emotional shocks, frights, disappointments, etc. of the present or past; how affected by a room full of people. Describe any fears or phobias; e.g., heights, claustrophobia, dark, thunderstorms, death, disease, robbers, animals, poverty, public speaking, etc.

6. As to appetite, tell what is craved or disliked, including such things as salt, sweets, fats, sour, spicy things, eggs, milk, cheese, ice cream, butter, yoghurt, chocolate, meats, fish, shellfish, chicken, smoked foods, fruits, vegetables, onions, garlic, soup, ice, cold things, warm things, bread, etc. Also, is there thirst or lack of thirst, and what type of drink and temperature of the drink is preferred? Is there any craving or aversion to coffee, tea, tobacco or alcoholic beverages (specify whether wine, beer and/or liquor)? Are there any ill effects (allergies or any adverse reactions) to any of the abovementioned items?

7. Do the symptoms remain the same or do they change character and/or shift from one place to another?

8. Describe all pains; what kind, what exactly it feels like, e.g., burning, stinging, throbbing, aching, bursting, stitching, stabbing, tearing, needle-like, tearing, etc., and whether constant, changeable, or periodical; also, in what direction it may go or extend, if any; whether it comes slowly or suddenly and also how it leaves. Mention those things that make the pain either better or worse, such as the effects of heat, cold, weather, time of day, pressure, touch, motion, position, etc.

9. Write down the time of day, night, month or season that you are better or worse; whether before or after eating, sleeping, moving, resting, exercising, when occupied, when thinking of your complaint, etc. Write just what things or conditions make you feel worse and whatever relieves the pain or sickness. This is important!

10. How are you affected by different kinds of weather, by cold, heat, dryness, humidity, an approaching storm, during and/or after storms, thunderstorms, frost, cloudiness, seashore, low or high altitudes, etc.?

11. Sensations are very important information! State just what kind, where, at what time they are better or worse, and whatever makes them better or worse. Tell about all sensations, however slight, strange, rare or peculiar, such as "as if___________," e.g., sensations as if floating, sensations as if cobwebs on face, sensations as if a body part is enlarged or feels smaller, sensations as if something alive inside the abdomen or inside the chest or inside the head, sensations as if someone behind you, etc.

12. In skin, scalp, or nail problems, tell the exact location, color, whether dry or moist, thick or thin, scaly, crippled, pimply, blistered, with or without discharged matter, warts or growths, appearance of surrounding skin; whether itching, burning, stinging, worse or better from scratching, and what else makes it better or worse, such as heat, the heat of the bed, cold, exercise, wool, water, etc. Tell of any enlarged veins, etc.

13. Describe discharges of any part, whether slight or heavy, the color, odor; if thick or thin, gluey or sticky; if causing redness or burning, rawness; color or stain; and what makes it better or worse and when.

14. Urine: whether pain before, during or after passing, color, odor, appearance, quantity, sediment, frequency, urgency (if hurried).

15. Bowel condition: color, odor, hard, dry, large, pasty, bloody, frothy, slimy, thin, watery, slender, flat, etc. How often, at what times worse or better, or how affected by certain circumstances; whether difficult, incomplete, urging without result; if the stool slips back in, if prevented by spasm of the rectum; or anything else peculiar.

16. Women are to give age at first menstrual period, how far apart, then and now; whether pain before, during, or after, then and now, and where; also where the pain may extend to, as to the back, sides, groins, thighs, etc. What kind of pain (see #7), what relieves or aggravates, how often the pains come. Tell whether there have been miscarriages. Tell how you feel in general, before, during and after the periods; sex desire or aversion, whether intercourse is normal, unsatisfactory, or painful.

17. Men are to give particulars as to male organs, if anything is not normal; whether any former disease or abuse; effect of intercourse; strength of sexual drive; frequency of masturbation; whether night emissions, etc.

18. Describe the effects of heat, cold, weather, bathing, getting wet, exposure to drafts, the sun, lying down, motion, beginning motion, the effects of perspiration; whether prone to lassitude, weakness or weariness and the effects of activity. Are you greatly influenced by being at the seashore or mountains?

19. Describe the details of your sleep. Do you sleep well or poorly? Do you have trouble falling asleep or staying asleep? Do you waken at a certain hour? In what manner; e.g., as from fright, from a dream, from a sensation of heat, from a physical pain or other sensation? In what position do you sleep? Do you stay covered or uncover? Do you uncover your feet at night? Are there any peculiarities associated with sleep, such as teeth grinding, perspiration, salivation (drooling), jerking, restlessness, talking or walking? Do you dream? Do you have any recurring dreams or dreams of a similar nature; i.e., similar theme, same object or person recurringly appears, etc.? Please describe your dreams in some detail and how you believe their meaning(s) relates to your waking life. Mention any other peculiarities of sleep.

20.. Using the guidelines given above, please write a narrative summarizing your principle complaints and the “reason" you think you became ill. How did your life situations, in the past or present, cause any stresses you may have experienced and/or developed any qualities and/or behaviors, e.g., selfishness, stubbornness, fearfulness, etc., in you that might have contributed to your illness. Similarly, did any physical, chemical, or biological trauma(s) contribute to your illness? Describe the significance of your illness to you, what your emotional reactions are to it, and what are your worries in regard to it.

21. Describe yourself (separate from the illness); what you feel are your central, personal strengths and weaknesses; include a summary of your life history focussing upon the most important events in your life - major griefs and losses, disappointments, the worst thing(s) that has (have) happened to you, and about your childhood. Discuss what is most important to you in life; also describe your favorite pastimes and passions, and your goals and aspirations for your life.

Thank you for taking the time to complete this homeopathic questionnaire. The more detailed, honest and candid are your answers, the better chance that your homeopathic physician has of ascertaining the correct, individualized, most deeply acting constitutional homeopathic remedy for the complete healing of your body-mind-spirit.