Go through the General Directions mentioned below.


Each question has three possible answers: “YES”, “NO” and “OCCASIONALLY.” Please answer them to the best of your ability by checking the appropriate box. The following directions indicate how you are to answer:
1. If you are having the symptom NOW or have it in regular, periodic cycles, then answer by checking the “yes” box.
2. If the question does not apply to your case, or you have never suffered from the symptoms before, then answer by checking the “No” box.
3. If the symptom occurs only occasionally and in no predictable pattern, then answer by checking the “occasionally” box.
4. Please answer the general question on the back page about why you are seeking alternative/ complementary medicine.
Please remember that I am only using this history form as an aid to help in determrning your overall general symptom picture. It is of paramount importance to me as your homeopathic physician to know you in all aspects-physical, emotional, mental and spiritual. I can only do this if you understand that homeopathy treats a patient holistically.
We ask that you give at least 24 hours’ notice in the event that you need to change the appointment date (on Friday for a Monday appointment). There is a charge for less than 24 hours to do so. The fee can be discussed either by calling the office or by speaking with the doctor.

Thank you for your help and cooperation