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Consultation Form
Take great care  as Homoeopathy is a complex science and accurate replies are vital to ensure correct prescriptions. 
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 insomnia?

• 1 –4 times   5 or more times   constantly

Was your condition caused or preceded by

• a stress at work
• a grief
• the exposure to dry, cold windy weather
• strong emotions
• over-excitedness
• exhaustion
• a shock or fright
• nervous tension
• repeating thoughts

Which, if any, of the following symptoms do you consider to be the main sensation of your complaint?

• a tendency to wake between 03.00 and 04.00 am  and remain awake
• nightmares
• anxious dreams
• nervousness and restlessness
• an empty feeling in the stomach
• a rapid changes of mood, laughing to crying
• dizzy
• sweating during sleep

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

• before midnight   after midnight
• at night   in the evening
• lying down
• sexual excess
• strong smells
• tobacco smoke
• noise
• fresh air
• cold temperature
• overeating
• too much alcohol   coffee
• warm rooms
• music

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

• short naps
• warmth
• lying down
• sucking ice
• sleep
• in the evening
• when alone
• fresh air
• eating
• after urinating

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

• an inability to relax
• waking is difficult
• you are waking late
• waking is frequent
• an overactive mind
• a fear that you will never sleep again
• great fear
• restless sleep
• you can only fall asleep on the right hand side
• you need the company of others and desire sympathy
• irritability
• discontentment or unhappiness

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.