Name Title Mr Mrs Ms Miss Dr
    First name
    Surname
    Date of birth

   Address
    House No & Street
    Town
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    Post code

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    Email
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   Payment details

    Card type 
           
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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)

Has the child suffered with colic in the last 2 years?

• no
• once
• twice
• more than twice

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

• swallowing air during feeding
• flatulence
• constipation
• dehydration
• anger
• eating fruit
• drinking milk
• teething
• Did the symptoms come on suddenly ?                 or slowly?

Which, if any, of the following do you consider are the main symptoms of the complaint?

• The baby’s knees are pulled up to the chin
• Shooting pain manifested by sharp movements and crying
• The baby screams at the slightest movement
• Violent colic with angry crying
• Gurgling in the abdomen
• Accumulation and retention of wind
• Pain with diarrhoea

Are any of the following additional symptoms particularly relevant to the child:

• Irritability
• Anger   
• Crying
• Bloated stomach
• Pain not relieved from burping
• Dry mouth
• Baby only calms down when picked up

Do any of the following make the child feel significantly BETTER?

• Gentle pressure applied to stomach firm pressure
• Warmth   Cool air   Cold compress
• Hot drinks
• Stretching out   Bending back
• Sleep
• Releasing flatulence
• Rest   Movement   Being carried
• Bending double
• Lying on abdomen

Do any of the following make the child feel significantly WORSE?

• Being fed
• After eating
• Lying on right side
• Touch 
• Noise   Bright lights
• Doubling up
• If the stomach gets cold
• At a particular time   yes    no        if yes      09.00pm    04.00pm    in the morning             at night    other
• Burping   After eating
• Heat
• Coughing

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.