Homeopathic Consultation

In her practice Dr. Maltais utilises Homeopathy, Naturopathy, & The Bowen Technique.

Questionnaire

Use this form to provide details to us for treatment. Information provided by you is kept strictly confidential. Therefore, please feel free to write all. You would appreciate that accuracy of prescription normally depends on accuracy and details of information provided to the doctor, so please fill in all the relevant columns and give us maximum details. It goes to your benefit.

The Consultation charge is $45.00. Please feel free to look over the entire questionnaire before making entries.

CONTACT INFORMATION

Please provide the following contact information.

Full Name
Sex	Male Female
Postal Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

PERSONAL DATA

Please identify and describe yourself.

Age
Height
Weight
Married/Single	Married Single
Occupation
Previous Occupation (if any)

SYMPTOMS/HISTORY

At times a person may have such symptoms which in his/her opinion, are not relevant or he/she does not tell it to doctor thinking that it might look funny or unbelievable. This is our belief that a person goes to a doctor only when he/she feels that some thing is wrong. We never grade any symptom as funny or unbelievable. Therefore, please write what you exactly feel.

1. Please tell us about your Medical History (if applicable)

2. Please indicate your MAIN Symptoms/Complaints here.
(Preferably in your own words. Medical diagnosis is also acceptable.
Results of any tests if available may also be given here)

3. What makes the above symptoms better or worse?
(e.g. heat, cold, motion, walking, lying, sleeping, rising,
sitting, eating, drinking, bathing, weather etc. etc.)

4. What time of the day (or season) symptoms are better or worse?
(e.g. morning, afternoon, late afternoon, night,
before midnight, after midnight, periodically, etc. etc.)

5. How do your symptoms appear or cease?
(Please click which ever is applicable)

Appear	Gradually	Suddenly
	Diagonally from right upper side to left lower side	Diagonally from left upper side to right lower side
	From below upwards	From above downwards
Cease	Gradually	Suddenly
	Not noticed
	Any detail/Comments

6. Did above complaints/symptoms appear after any specific event?
(e.g. stress, grief, shock, accident, child birth, eating any special item etc. etc.
Please give details.).

7. Are you also suffering from any of the following diseases?
(Please give details of the Disease where applicable)

Any Allergy
Arthritis
Asthma
Blood Pressure
Bronchitis
Cardiac Disease
Chronic Constipation
Diabetes
Epilepsy
Hemorrhoids
Any other

8. Please answer following questions.
(With details where required)

Soles feel hot and burning
Palms feel hot and burning
Hands remain cold
Feet remain cold
Thirst (excessive, normal, no thirst)
How frequently you drink water and in what quantity?
What is your usual blood pressure?
Do you get any hot flushes (if yes, under what conditions) ?
Condition of tongue (e.g. white, furred, dirty looking etc.)
Condition of nails (e.g. color, cracks, spots etc.)
Any Warts or Moles any where on body?
How is the odor of your stool, urine and sweat etc. (normal or offensive)?
Color of Urine (first urine in the morning). Urine can be collected in a colorless glass container for observation. This column is optional but preferable.
How much tea and coffee do you take every day?
Have you used homeopathic medicines before?
Are you alcoholic?
Any Artificial item (e.g. any metal, plastic, or small machine etc.) embedded in your body?
How do you feel when you wake up in the morning?
Addiction to any drug?

9. How is your pulse?
(Please fill this column. It is important.)

How many beats per minute?
Is it found on the surface and can you find by light touch?
Do you find it on exerting some pressure?
Difficult to find or is found in depth on exerting much pressure.
Is it regular or do you find some beats strong and some beats weak?
Any beats missing?

10. Do you fear, love or hate any thing special? (if so, what and when?)
(e.g. Height, darkness, death, people, water etc. etc.)

11. How do you view yourself?
(You may click as many items as applicable)

Always in hurry	Anxious
Careful	Careless
Fault finding	Indecisive
Indifferent	Irritable
Weeping easily
Any other

12. Are you mentally or emotionally sensitive to anything?

13. Do you get frequent headaches?
(If yes, please give the details)

Which part of head?
How often?
Which time of the day?
Which posture (e.g. lying, standing, sitting, walking etc.)?
Any effect of heat, sun rays, sun rise or sun set?
Does headache affect your vision?
Any nausea or vomiting during headache?
What makes it better? (e.g. pressure, covering, heat, rest, sleep, warmth, cold, bathing etc.)
What makes it worse? (e.g. pressure, heat, talking, warmth, cold, motion, moving eye balls, turning head, cold etc.)
Did you ever have any head injury? (whether blunt, bleeding, long ago)
Any other detail?

14. Do you have any skin disease?
(If yes, please tell us all the details.)

Which part of body?
Name of disease (if possible)
Condition (e.g. dry, moist, oozing, itching, cracked, scaly etc.)
Does itching give voluptuous feeling?
What makes it better or worse? (e.g. touch, warmth, cold, bathing, any particular climate, scratching, cold/warm applications, covering etc. etc.)
Any other detail?

15. Please list any strong Cravings or Aversions to particular items of foods.
(e.g. salt, fat, milk, meet, vegetables, sweets, tea, coffee, cold drinks etc. etc.)

Cravings
Aversions
Eatables that trouble you in general

16. Female patients only.
(Please tell us about symptoms/problems or things
which you feel are not normal and bother you.)

17. Male patients only.
(Please tell us about symptoms/problems or things
which you feel are not normal and bother you.)

18. Please give details which you think have NOT been covered above.

Thanks for selecting Dr. Maltais as your Homeopath & health advisor.

Press once.

After the form is sent, press the add to order button to pay the $45.00 Homeopathy Consultation Charge.

We will now study your case and if necessary, contact you for any further information or clarification. You will soon receive your prescription along with other necessary details.

All the best, Dr Lise Maltais