Online Consultation

Your consultation will be with David Doré. Patients medical details will not be disclosed to anyone as is the current homeopathic practice.

Please fill in all the sections that are appropriate for you and give me all the information required so that I can plan you homeopathic treatment accordingly.

When I receive your completed form and payment I will assess your case and establish a treatment plan for you. Your homeopathic treatment will be forwarded to you by post.

Pay online with your credit card. Payment can be made by credit card using the PayPal option on this site. It is a secure online payment service for maximum security.

Your Homeopath fee for this treatment is UK £45.00 and your Credit Card will be debited with this amount.

Please provide the following information:

Name:


Title

Street Address


Zip / Postal Code

County


Work Phone


Home Phone:


Fax:


Email:


Please identify and describe yourself:

Date of birth:


Sex:
Male Female

Height:


Weight:


Occupation:


Previous Occupation:


Married / Single:


Children:


Please describe what you look like, e.g. typical clothes and expression?


Are you taking any homeopathic remedy, conventional medication, herb, vitamin or mineral supplements?


Homeopathic Questionnaire

Please indicate your MAIN symptom/complaint here.
(A medical diagnosis is acceptable, but it is also preferable to use your own words).


What makes the above symptom better or worse?
(eg heat, cold, motion, walking, lying, sleeping  etc.)


If this is not the first occurrence please describe any previous problems of this kind.


Please describe anything that you feel is associated with the current symptoms that is unusual, rare and/or peculiar or any other information which you wish to add.


Please indicate any other symptoms here.


What makes the other symptoms better or worse?
(eg heat, cold, motion, walking, lying, sleeping  etc.)


Did any of the above appear after a particular event in your life?
(eg stress, grief, shock,an accident, childbirth, unhappy relationship etc, etc).


Do you suffer from any phobias or anxieties?
(if so what and when?)


If YES to the above question, did the problem appear after a particular event?


How do you view yourself?
Very anxious
A little anxious
Not anxious
Placid

What about your memory? Your understanding? Your concentration? Any tendency to make mistakes?


Do you suffer from anticipatory feelings of any kind?
(eg going out, meeting people, undertaking new things etc, etc).


How do you respond to, (or absence of) company?
(Also please tell us if you are a loner or the soul of the party!)


Are you mentally or emotionally sensitive to anything?


How would you describe yourself and your character?


Disposition (how do others perceive you?).
Irritable
Quiet
Very talkative
Gregarious
Restless
Normal

On a daily basis, which (troublesome) emotion do you deal with the most?


What makes you mad?
(for example partner squeezing new tube of toothpaste near the top rather than at the bottom, is it a physical or emotional response, please describe it?)


What was the saddest or most traumatic experience in life
(if any?)


Which season or temperature are you unhappy with?
(please describe in detail how it makes you feel?)


Have you had any operations e.g. tonsils removed and if so when at what age were you?


What accidents have you had,for example broken left arm as a child, bitten by a dog, fallen of a bike, and if so please describe as much as you can remember and what age where you?


Headaches/Migraines (if applicable).

How often?


Which part of head?


Describe the character of pain


Nausea or vomiting?


Does your vision remain normal?


Other disturbances during pain?


What gives you relief? (eg pressure etc)


What makes it worse?

Skin problems (if any)

Name or description


Which part of your body?


Skin  (eg dry, itching, cracking etc)


What aggravates/improves skin?

Please list any strong cravings or aversions to particular foods.(eg salt, fat, chocolate etc)

Cravings


Energy and Interest in life.
(How would you describe yourself in terms of the above statements?)


Bodily functions and discharges
Please detail what is normal and what is unusual or troubling for you in relation to temperature, mucus, smells, bowels, and genital functions.


Can you describe any problems of the senses, hearing, vision, smell, taste


Can you describe your home circumstances and important relationships?


What are your passions and leisure pursuits?


At what time in the twenty four hours do you feel the blues, depressed, sad, pessimistic?


In time of depression, how do you look at death?

Please tell us about your Medical History
(If it applies to you, or family members, parents, grandparents).

Depression
Bronchitis
Cancer
Epilepsy
Allergies
Gland Swelling
Eczema
Diabetes
Arthritis
Psoriasis
Asthma
Alcoholism
Warts
Blood Pressure

Other:

Female patients only.

(Please tell us about symptoms or disturbances that are troublesome to you.)


At what age did your periods begin?


How frequently do your periods come?


Please describe their duration, abundance, colour, and odour


Please describe any other details that may be relevant


At what time in the twenty-four hours do they flow most?


How do you feel before, during and after your periods?


What about your character, feelings, or behaviour before, during and after your period?

Male patients only.

(Please tell me about symptoms or disturbances that are troublesome to you.)

Payment:
Pay Pal

David now has all the information necessary to establish your treatment plan.
Thank you for choosing David Doré as your health provider.
Please click the "Submit Form" button below.
Your Homeopath fee for this treatment is UK £45.00 and your Credit Card will be debited with this amount.