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. 
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) 


Age

        (Please Tick)

Are you taking HRT? 

• yes   no

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

• a hormonal imbalance
• overwork
• an emotional or physical shock

Which, if any, of the following do you consider are the main sensations or symptoms of your condition?

• anxiety during hot flushes
• left sided headaches
• a sinking feeling in the pit of stomach
• heavy menstruation
• sudden fainting spells
• a tendency to thrush
• an indifference to loved ones
• flushing   dizziness
• sweating
• a need for comfort and sympathy

Do you have any of the following health related problems?

• ovarian cysts
• tumours
• osteoporosis
• circulatory (HBP)
• uterine bleeding
• varicose veins

Do any of the following make your condition significantly WORSE?

• prolonged standing
• heat
• being in a stuffy room
• washing
• before menstruation
• cold
• tobacco smoke
• hot, damp conditions
• before thunderstorms
• a draught
• the cold   the damp
• excitement
• touch
• after a warm bath
• sleep
• grief
• on waking
• rich, fatty food
• at a particular time   yes   no   11.00 am   
   02.00am – 03.00am  
  other

Do any of the following make your condition significantly BETTER?

• eating
• sleep
• exercise
• fresh air
• cold drinks
• a cold compress
• the thundery weather
• in the morning
• when constipated
• lying on right side
• wrapping up warm
• bathing in cold water

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

• an aversion to sexual intercourse
• weight gain   
• panic attacks
• suspiciousness and tendency to talk too much
• anxiety and fear that memory loss and lack of  concentration will be observed by others
• phobias
• perspiration on the face
• a craving for sweet foods
• insomnia
• you weep at the slightest cause
• sighing
• a fear of death and insanity
• a difficulty expressing emotions
• depression
• hysteria

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.