Name Title Mr Mrs Ms Miss Dr
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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) 


Age

        (Please Tick)

During the past two years, how many times have you suffered with PMS?

• 3 times or less   5 times –9 times  
  10 times or more

Is your condition caused or preceded by

• a hormonal imbalance
• the approach of menopause
• stress
• being overweight
• overwork

Which, if any, of the following do you consider best describes your symptoms?

• fluid retention and particularly swollen breasts
• painful joints
• a lack of energy and weakness
• a vaginal discharge or thrush
• a bloated stomach and swelling to upper face
• associated headaches, nausea and dizziness
• a tendency to gain weight before the period
• greasy skin and acne
• a headache worse on waking and left sided
• you become anaemic after heavy 
  painful periods
• sweating profusely
• a backache in the lumbar region
• marked sugar craving
• bloated with a strong need to pass wind

Does anything make your symptoms feel significantly BETTER?

• eating   cold drinks
• sleep
• crying
• vigorous exercise
• loosening clothes
• fresh air   heat
• when constipated
• in the morning
• at the start of the period
• in summer   warm dry weather

Does anything make your symptoms feel significantly WORSE?

• warmth and in the sun
• a draught
• cold
• cold damp windy weather
• a hot bath
• hot drinks
• before thunderstorms
• the early morning
• in the evening
• at night
• between 2.00am and 3.00am   between 4.00pm and 8.00pm
• tobacco
• mental exertion
• sympathy
• anticipation
• touch
• tight clothing

Are any of the following symptoms particularly relevant to you?

• a difficulty concentrating
• an indifference to loved ones
• depression, self-pity and sudden tearfulness
• fear in a crowd
• a tendency to talk too much
• unhappy and discontented
• very insecure and anxious
• extreme introversion
• high moral standards
• very dry lips and skin

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.