The H2H questionnaire
The H2H questionnaires are meticulous databases whose information we will use to provide you with a homeopathic cure. Depending on your need (Adult or Child), Please take your time to fill up the form as accurately as possible. If there is any additional information that you feel is relevant, please append it in the text box presented below David Johnson & Dr. Leela.

Please answer all the following questions as honestly as possible with as much detail that occurs to you. It is important that the information you give is as authentic as possible. Most often seemingly unimportant symptoms are the basis for a homeopathic prescription. All that you answer will be in the strictest confidence. If a question does not apply to you, please answer - NA

     
Name: 
Date of Birth:   [dd-mm-yyyy]
 
Postal Address: 
Phone No: 
E-mail Address:
 
Occupation: 
Day/Month/Year: 
 

Please describe yourself (patient) in appearance including approximate weight and height.


 
 

Describe your chief complaint in detail. The following are some of the relevant details required.

i)  If this is a physical problem, which part of the body is affected?  Please specify the location.  When did this problem begin? Is it periodic or recurrent?  If yes, then how often?  For how long do the symptoms last?

ii)  Describe the symptom(s) you are experiencing.  Explain this with the area of  distribution and the sensation experienced. Please give complete details and describe what you feel. For eg: the pain is intense, like a knife stabbing me; or the itching is so unbearable, I wish I could cut that part off; or I feel so anxious, it seems like the end of the world has come.

iii)  What are the modalities that cause the trouble to worsen or improve?  Give details with regard to time, temperature, climate/weather, food items eaten, applications, movement, rest, and any emotional changes which occur.
 
iv)  Add any other symptom that you find related to your chief complaint that is not mentioned above, including how you feel in general while the complaint is present.

v)  What circumstances preceded or were occurring around the time that your problem began to occur?


 
Describe in detail in the above format any other problems that you may be experiencing, eg., headaches, bowel related problems, colds/sinusitis, backaches, hypertension, diabetes, etc.

 
 

Past History:
Please give details of the different sicknesses you have suffered from since childhood with approximate dates in month or year. Also detail the treatment used for the condition and the intensity of symptoms experienced. Anything out of the ordinary is appreciated. Please add the present prescription of medicines that you are on as well as attach the relevant investigations chronologically

 

Family History:
What is the family history of serious illness?
(Ex: hypertension, diabetes, heart problems, cancer, joint problems, asthma, chronic skin diseases) If you have lost any parent or family member, what was the cause of death? This above history includes your brothers, sisters, parents, grandparents and uncles and aunts on your father's and mother's side. Your first cousins may also be included.


 
 

General Symptoms
Thermal State: Do you feel more hot or more cold?


 
Which types of weather make you comfortable or uncomfortable?  Are there any types of weather that aggravate your symptoms?

 
Do you prefer having a fan or draft from a window, or do these bother you?

 
Do you prefer indoor or outdoor air?

 
What sort of covering do you use throughout the year?

 
Do you prefer a hot/warm or cold bath throughout the year?
 

Perspiration
Do you perspire a lot?  


 
Which part(s) of the body perspire most?
(eg. palms, soles of feet, head, face, upper lip, underarms, back, etc.

 
Does the perspiration have any smell? what type?

 
Does it stain the clothes, which is difficult to wash off?
 

Thirst
Do you feel thirsty? How much water do you drink per day? Do you tend to sip or gulp liquids? Do you prefer it cold or warm? How much do you drink at a time?


 

 

Food Cravings
How is your appetite


 

What are the food items that you enjoy most?                 


 

What taste in food do you prefer?


 

Do you prefer non-veg food or vegetables? If non-veg, do you prefer meat, fish or chicken?


 

Do you like milk and eggs?


 

Do you like sweets? Which type?  


 

Do you feel like eating indigestible things like Chalk, mud etc?
(This question pertains to ones own personal choice in taste from childhood and does not refer to a diet that one has adopted.)

 

Food aversions
What are the food items that you dislike the most?


 
What taste in food do you avoid as you do not like the taste?
 

Tongue:
Look in the mirror and observe your tongue.  Does it look pink or pale or red?


 
is it dry or moist?

 
Does it have a coating? 

 
If yes which part of the tongue is coated?

 
What colour is the coating?
 
 

Bowel:
Do you have any problem with stool?
 

 
Are you regular?

 
If you have constipation, since how long?

 
Is the stool hard or soft?

 
Do you have a normal urge or is it poor causing you to force?
 

Bladder:
 Do you have any difficulty with urination?  


 
Any past or current history of urinary tract infections?

 
Do you get up at night?  

 
How often?

 
 

Sleep:
Do you sleep well?


 
If not describe the problem in detail.

 
Do you have a preferred position for sleeping?

 
 

Male Genital System:
Please list any problems related to sexual anatomy and function, eg., impotence, decreased desire, diseases, hydrocele, surgeries, etc.

 

Female History:
Menstrual History: When was your first menstrual period? Do you have regular cycles? Is the flow scanty/moderate/heavy? Do you suffer from any pain, backache, white discharge etc. before/during/after menses?


 
Obstetric History: How many children have you had? Were they normal deliveries? Did you have any miscarriages or abortions?

 
 

Mind Symptoms
(This part pertains to your personality and nature). Describe your opinion of yourself, and if necessary get a family member to help you


 
Detail your immediate family, ie., what is your position in the family (father/mother/child)?  With whom do you live?

 
How many siblings do you have and among your brothers and sisters, at what position are you? Eg. Eldest, middle, youngest.

 
What is your educational background? What circumstances caused you to stop, or allowed you to continue?

 
How would you describe your personality?

 
Please provide a general description of your personality.  

 
Compare yourself to another brother, sister or friend.  In what ways do your personalities differ?

 
What do you enjoy doing in your free time? (hobbies, studying, games, outings, travel, dancing, etc.)

 
What are your highest priorities in life?  What makes these priorities important for you?

 
Give examples of past or current situations that are or have been especially stressful.  What has been your response to these situations?  How have those situations shaped you?

 
Describe your relationship with others, eg., your immediate family, extended family, friends or colleagues.  What observations about your behavior do you find others making? .

 
What things or situations can make you uncomfortable or possibly fearful?  (eg., certain animals, people, robbers, being alone, water, narrow places, heights, flying, accidents, dark, death, disease, sudden noises, thunderstorms, the future, unknown, performance, etc?)

 
Some people keep their home or work space very neat and orderly, and others have piles but may also know where everything is.  What is your tendency?

 
What hurts have you endured in the past, and what emotions do you feel when thinking about those hurts?  

 
How would you describe your confidence level?  How do you feel about taking on new projects or enterprises?

 
What aspects of your nature are you unhappy about, and feel you need to change?

 
Is there any present situation, domestic, personal, economical or social worrying you?  Please give some detail.

 
What emotions--anxiety, fear, anger, grief, etc., are especially troubling for you?

 
Describe situations which have made you feel doubtful or suspicious.

 
How are you affected by exercise?

 
Describe situations which have made you feel jealousy or envy.

 
When upset, some people look to others for support, while others tend to keep the problem private and don't look for consolation.  Where are you in that range of response?

 
What situations have made you feel sad or depressed?

 
In what areas of the body do you experience emotions, eg., neck/shoulder tension, tightening of the throat, stomach upset, etc.?

 
What situations have made you angry?  Some people anger easily and forgive quickly, others get angry slowly and forgive slowly.  How would you describe yourself?

 

What else can you add to the above?  What points do you feel are most important for someone to understand who you are?


 

Have you had any childhood experiences that have had a deep impact on you? Please explain.


 
Have you had Psychotherapy, Counseling, Religious Experiences or Healing therapy before? How has this changed your attitudes or helped you?
 

Dreams:
Please enumerate the type of dreams you get, especially if they've left a strong impression or if they're recurrent.  Even if you don't remember your dreams, try to think about any particularly strong or recurrent dreams you've experienced at any time of your life.  If the dream or dreams was/were particularly significant for you, please describe in detail.
(For example, do you dream of family, known people, unknown people, ghosts, animals, flying, falling, water, jungles, God, snakes, etc?)