Homeopathic questionnaire:

Transcription

1 Homeopathic questionnaire: Name PERSONALITY and TEMPERAMENT WEEPING/SIGHING Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Weeping improves your feelings or symptoms Warnings/admonitions cause weeping Weeping alternating with moods (irritability, laughter, cheerfulness) loud Sobbing Weeping for no apparent reason, involuntary Consolation aggravates weeping Moved to tears by sad stories Frequent sighing Hysterical Moody Anxiety causes weeping Weeping when thanked SADNESS Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Dissatisfied Complaining Resentful Sulking/brooding/dwelling Suppressed sadness Suppressed feelings Cheerful Sad or melancholy Like to think/dwell on sad subjects Difficult to please Boredom Hurt feelings Feel unloved Indifferent to pleasure I am sentimental Affected by sad stores, news events

2 ANGER Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Physical problems from emotion of anger Dictatorial/bossy only at home or with people who are below your position Pessimistic Suppressed anger Prone to contradict others/contrary Anger from contradiction/or criticism Violent anger Throwing or striking in anger Swearing in anger Vengeful Interruptions annoy me I am competitive ANXIETY Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always How anxious are you about health about opinion of others about health of others in company about being late when someone expects something from you from conversation speaking in public from noise about trifles when thinking about anxiety before your period/menstruation (females only) about opinions of others Anxiety improves on walking in open air Does motion or exercise improve anxiety PRECISION Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Conscientious about trifles Meticulous Critical of friends or acquaintances Cautious

3 PRECISION - Continued Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Critical of family members GUILT Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Do you need company How often does consolation aggravate you How often do you need consolation Does it bother you to have strangers around you Do certain types of people bother you (to have them near friends husband/wife children one particular person opposite sex How often do you feel guilt Inhibited (feel uncomfortable with expressing certain feelings/emotions) Does it bother you when others come near you Do you enjoy company MEMORY Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Trouble with concentration in conversation what was read or studied while talking while writing confusion after eating on attempting to concentrate after sleeping in a warm room FEELINGS of HURT Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Feel you are being injured Feel abandoned/forsaken/deserted Feel that someone is following you or behind you Feel disgraced/insulted

4 FEELINGS OF MISC Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Jealousy Tend to theorize Optimistic Clairvoyance Able to sense others emotions Mood better after vigorous exercise Impatience Emotions stable Mood swings (not related to menses) Mood swings related to menses Ambitious Moody Suspiciousness Egotistical vanity (false pride) QUICKNESS Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Moves slowly Moves rapidly In a hurry Tendency to be late Tendency to be on time Procrastinates Rapid thinking Slow thinking Talkative Changing subjects quickly How calm/laid back are you? LOVE and SEX Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Lack of sympathy Sympathetic Affectionate Showing love emotion to partner How often would you like to masturbate How often would you like to have sex Shows affection easily to strangers Dislike to be touched

5 ENERGY Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Enjoys mental exercise For physical exercise Lack of stamina Yielding/passive FOOD PREFERENCES Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Overeats to bursting point Fruits aggravate symptoms Dislikes eggs Beans, peas aggravate body Likes starchy foods Likes bread and butter Likes rich fatty foods Rich fatty foods aggravate the body Likes ice cream Like peanut butter Dislikes pork Dislikes onions Likes eggs especially soft boiled Likes salty food Likes sweet food Likes spicy Garlic aggravates body Onions aggravate body Likes milk Likes warm food and drinks Dislikes warm food Dislikes warm food Likes raw foods Dislikes mixing foods together Dislike for breast milk as infant Hot drinks aggravate body Iced drinks aggravate the body Likes ice cold drinks Likes carbonated beverages Likes alcohol Alcohol aggravates the body, though likes alcohol Likes coffee Dislikes coffee Coffee aggravate body Onions aggravate body

6 FEARS Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always heights enclosed spaces snakes thunderstorms sharp pointed objects ghosts darkness burglars mice/rats water failure of business/job being late everyone must hurry being hurt emotionally food poisoning illness insanity death cancer failure in business poverty loss of control what other phobias do you have that are strong? GENERAL BODY SYMPTOMS Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Feet are hot in bed and sticks them from out of covers Chilly and better heat Feet are sweaty and smelly Ailments worse after sweating Head is sweaty in bed Ailments worse from prolonged standing Ailments worse in cold Ailments better in damp weather Ailments worse in wet weather Ailments worse in cold dry weather Ailments worse in windy weather Ailments worse open air Ailments better in open air Bad breath and tongue coated white Warts and moles on body and face

7 GENERAL BODY SYMPTOMS - Continued Please circle your choices 1 - Never 2 - Sometimes 3 - Often 4 - Always Ailments better from sea air or water Ailments worse from sea air or water Ailments worse from bathing in hot water Headaches before thunderstorms Sensitive to odors Sensitive to tobacco Sensitive to sunlight Sensitive to artificial light Sensitive to slight noise Faintness or headaches on missing a meal Feel better fasting Feel better after a short nap Ailments worse from 4-6 pm or 4-8 pm Body tends to be warm and made worse by heat Ailments are worse in stuffy room