Name Title Mr Mrs Ms Miss Dr
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Consultation Form
Take great care  as Homoeopathy is a complex science and accurate replies are vital to ensure correct prescriptions. 
Some of the questions may seem a little unusual, however all of the questions have relevance to a Homoeopathic consultation.
You will receive a response by email within 24 hours (Sundays and weekdays only) and the appropriate homoeopathic remedy or remedies will be dispatched to you together with instructions and advice within the same period by first class post.

Name of patient (if different from payee) 

Gender male    female
Age

        (Please Tick)

Within the last 2 years how many times have you suffered with catarrh /sinusitis ?

• 1 –2 times
• 3 - 4 times
• 5 or more times

Was your condition caused or preceded by any of the following:

• an infection
• an allergic response
• vigorous physical exercise
• exposure to cold dry, windy weather

Which, if any, of the following do you consider the main sensation of your nasal symptoms?

• thick white mucus drips down back of throat
• clear mucus like the white of an egg
• catarrh with constantly runny nose
• catarrh with extreme sensitivity to strong smells
• nasal discharge is green/yellow
• crusts and cracks inside the nose
• nosebleeds
• pain above the eyes or in the right cheekbone
• rawness, burning
• sinusitis with stringy mucus
• sinusitis with facial tenderness
• nose stuffed up at night
• nose blocked worse on the right side, sleeps with mouth open
• oversensitive to smells

Do any of the following things make your nasal symptoms significantly WORSE?

• when you are in a cold and draught
• in the heat
• the sun
• the damp weather
• fresh air
• fatty foods
• too much salt
• cold or sweet food
• beer
• before menstruation   during menstruation
• exertion
• first movement
• stuffy rooms
• being touched
• lying on back
• at any particular time  yes   no
   04.00 – 08.00 pm   morning   evening   night   other

Do any of the following things make your nasal symptoms significantly BETTER?

• cold weather dry weather
• cold drinks
• fasting
• hot food and drinks
• massage
• bathing your face in cold water
• fresh air
• sleep
• applying hot compresses to sinuses
• crying and sympathy
• warm surroundings
• wrapping up the head warmly

Are any of the following additional symptoms particularly relevant to you?

• tearfulness
• cold and chilled
• metallic taste in mouth
• irritability

Press the 'submit' button below to send your consultation and payment. You will receive an acknowledgement within 24 hours (48 if sent on a Saturday). 
A qualified homoeopath will review your form and prescribe appropriate homoeopathic remedies which will be dispatched by first-class post with appropriate instructions.