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

• 0 times   2 - 3 times   3 or more times

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

• overheating
• food poisoning
• eating too much ripe fruit or ice cold food
• eating an excess of fatty/salty/sweet/spicy food
• an angry outburst
• a chill or cold
• an acute illness
• nervous anxiety (for example before an exam or performance)

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

• a cramping pain which causes you to double up
• an urgent need to pass stool in the morning
• diarrhoea accompanied by severe flatulence
• uncertainty as to whether flatulence or stool will be passed
• a burning pain in the abdomen
• discomfort often felt on right hand side
  felt in left hand side
• not relieved by flatulence or burping
• diarrhoea alternating with constipation
• diarrhoea accompanied by vomiting

Do you have a strong craving for any of the following:

• salty food   sweet food   coffee   cold food fruit    vegetables

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

• warmth   in a cold temperature   fresh air
• pressure
• hot drinks    cold drinks   fasting
• lying on right side   lying on abdomen
• in the evening/at night
• after a nap
• after stool

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

• warmth   hot weather   cold air
• at night   in the morning
• eating   sweet food   milk
• drinking
• mental exertion
• motion
• the pressure of clothes
• before or during menstrual period
• at a particular time      yes   no  
  04.00 – 08.00pm   04.00am      
  other 

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

• an associated feeling of anger
• chilliness
• restlessness and anxiety
• a cold sweat on forehead
• a thirst for cold water

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.