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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 have you suffered with constipation

•  4 or more times    2-3 times    Never

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

• a fright
• an emotional trauma. e.g. angry outburst
• a cramping spasm in the anus
• chronic use of laxatives or painkillers  
• drinking milk
• pregnancy
• travelling away from home

Which, if any, of the following do you consider is the main sensation of your complaint:

• lack of desire to open the bowels unless full
• stools are soft and clayey
• stools are hard balls
• despite urgency to pass stools, few or none are passed
• much straining to pass stools
• flatulence and belching
• an unfinished feeling
• constipation alternating with diarrhoea
• large dry stool which is difficult to pass

Do you have any strong food cravings for:

• salty food    
• sweet food    
• coffee    
• cold food    
• fruit                  
• vegetables    
• indigestible food

Do you have any aversions to the following foods:

• meat   beer   milk

Do any of the following make your symptoms feel significantly BETTER?

• passing a stool while standing
• warmth
• hot drinks cold drinks
• being in a cold temperature
• fresh air
• fasting
• lying on the right side
• lying on your abdomen
• lying still
• in the evening   after midnight
• after a nap

Do any of the following make your symptoms significantly WORSE?

• warmth
• cold air
• hot weather
• eating
• starchy foods
• mental exertion
• motion
• the pressure of clothes
• before or during menstrual period
• at a particular time   yes    no        if yes    04.00 - 08.00pm    03.00 - 04.00am                     in the morning    at night                               other

 

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

• you have associated feelings of anger
• you are sensitive to noise
• painlessness of complaint
• irritability and headaches

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.