Name Title Mr Mrs Ms Miss Dr
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    Surname
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    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)

Within the past two years, how many times have you suffered with headaches/migraines?

• O times   1 - 3 times   4 - 6 times   7 times or more

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

• an exposure to cold dry wind or a draught
• getting wet
• a shock or fright
• heat - either from a fever or from exposure to the sun
• your head getting cold wet or overheated
• a stress or a worry especially about work
• an emotional stress   grief
• drinking too much alcohol
• muscular tension in the neck and back
• eyestrain
• a head injury
• exhaustion
• hormonal changes   menopause   PMS
• overeating
• ice cream

If you are suffering from any pain is it located at

• the forehead   the occipital (back) of head 
• the left side of head    the right side of head
• above the left eye    above the right eye    both
• behind the left eye   right eye   both
• the top of the head

Are any of the following sensations or symptoms particularly applicable to you?

• the pains come on suddenly   slowly 
• a tight band around the head 
• feeling as if a nail is being forced through side of head
• bursting pains
• throbbing pains
• drawing pains
• burning pains
• bursting pains
• stabbing pains
• sore pains
• catarrhal symptoms

Do you suffer from any of the following symptoms?

• your palms and soles are burning
• dizziness
• nosebleeds
• red, congested or sore eyes
• sweating
• belching
• cold feet
• nausea or vomiting
• hunger
• dryness of mucous membranes

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

• cold applications   warmth   fresh air
• eating   fasting
• sleep/rest   closing the eyes in a dark room
• pressure
• washing the hair   wrapping up the head
• standing or sitting   lying down   walking
• after urination
• sweating

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

• a hot environment   the cold fresh air   bright lights/sun
• tobacco smoke   coffee or alcohol   strong smells
• movement or touch
• lying down   lying on the left side    walking upstairs
• excitement
• noise
• after eating
• menstruation
• physical exertion
• at a specific time        yes   no   
  10.00 –11.00a.m     03.00 – 04.00a.m          other
• at midday   at night

Which, if any, of the following additional symptoms is PARTICULARLY relevant to you?

• chilled and feeling cold
• extremely irritable
• you cannot stand the touch of clothes on skin
• feeling very weepy, clingy
• very anxious
• noticeable dark circles under eyes

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.