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

   Address
    House No & Street
    Town
    County
    Post code

   Contact details
    Email
    Day time telephone
    Fax (if any)

   Payment details

    Card type 
           
    Card number
    Expiry date
    Issue No. (Switch only)

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 past two years, how many times have you suffered with cystitis?

• 0 times   1- 3 times   4 or more times

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

• an infection
• stress
• too much spicy food/alcohol /caffeine
• suppressed emotions/ indignation
• sexual intercourse
• catheterization
• lack of sleep
• getting cold or wet
• overexertion
• antibiotics

Which, if any, of the following sensations or symptoms are you experiencing ?

• Burning, cutting pain in the lower abdomen
• Fluid retention
• Aching in the back
• Small amount of urine passed
• That a drop is constantly trickling through the urethra
• Cutting pains at the end of urination
• Stinging pains

About your urination. Is it

• constant   frequent
• incomplete
• painful
• urgent

With regards to your urine, are any of the following applicable?

• Blood
• Burning
• Cloudy
• Copious
• Dark
• Green
• Hot
• Pale
• Red
• Scanty
• Smelly
• With sediment

Do any of the following make the complaint significantly BETTER?

• Beginning urination after urination
• Heat   hot bath   cold
• Cool compress
• Cool drinks  
• Pressure
• Bending double
• Lying on back
• Riding in the car
• Night   morning
• Sleep

Do any of the following make the complaint significantly WORSE?

• When not urinating   during urination   at the end of urination
• Heat
• Restricting clothes
• Movement   lying on back   sitting  
  walking   motion   rest
• At any specific time   yes   no   afternoon night   03.00-04.00am   
  other
• Cold, windy weather
• pressing the bladder
• Not drinking enough
• During your menstrual period

Which, if any, of the following additional symptoms are particularly relevant to you? 

• Weakness and prostration
• Great thirst    thirst-less
• Resentfulness and anger
• Restlessness
• Desire to be left alone
• Irritable
• Tearful and desiring sympathy
• Intensity and rapidity of cystitis

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.