New Patient Questionnaire. Today s Date: Date of Birth: Name: Home Address: City: State: Zip: Home Phone: Work Phone: address: Referred by:

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Pamela A. Pappas MD, MD(H) Classical Homeopathy for Mind, Body, and Soul 8114 E. Cactus Rd., Suite #240 Scottsdale, Arizona 85260 Phone: 480.656.9218 Fax: 602.626.3695 E-mail drpam@drpampappas.com New Patient Questionnaire Today s Date: Date of Birth: Name: Home Address: City: State: Zip: Home Phone: Work Phone: Email address: Referred by: Primary Care Physician: Previous Homeopathic treatment? Gender: M F Marital Status Height Weight Occupation: What makes you seek homeopathic treatment at this time? 1

What do you feel may be contributing to these issues? MEMBERS OF YOUR HOUSEHOLD: Name Age Relationship MEDICATIONS Drug Name When started Dose/Frequency For? MEDICINAL HERBS, VITAMINS, SUPPLEMENTS, HOMEOPATHIC REMEDIES Name When started Dose/Frequency For? Allergies (Environmental, medications, etc.) Please describe reaction if applicable: HEALTH HABITS How many times each week do you exercise for 20 minutes or more? How do you exercise? 2

How do you relax? Do you have an active spiritual practice? Do you enjoy your work? Hours worked/week Quality of relationship with significant other? Other support systems? Do you use... Coffee No Yes Amount Tea No Yes Amount Alcohol No Yes Amount Tobacco No Yes Amount Recreational drugs No Yes Type/Amount Are you concerned about your drug/alcohol use? HOSPITALIZATIONS and/or SURGERY DATE OTHER MEDICAL ILLNESSES, ACCIDENTS, INJURIES? BIRTH HISTORY Place of Birth Home Hospital Other How was your mother s health while she was pregnant with you? Any complications during her labor with you? 3

MEDICAL STUDIES Have you had any of the following? If so, when and why? Chest X-ray? TB Skin Test? MRI/CAT Scan? Ultrasounds EKG? CBC/Blood Chemistry Other diagnostic studies? Eye exam Dental exam What experiences in life have affected you deeply? What are you most sensitive to? (noise, odors, lights, pain, heat, cold, etc?) What are your fears and anxieties, past or present? (i.e., situations, people, animals, events, etc) What do you enjoy in life? Activities? Hobbies? How is your sleep? What is your favorite sleep position? How is your energy? Are there times when it is lower or higher? 4

How is your sexual interest/drive? Please describe ANY dreams that you recall, vivid or recurrent, or themes of dream. (please use back of sheet or another piece of paper if needed) What specific foods or flavors do you most LIKE to eat, crave, or enjoy? What specific foods or flavors do you most DISLIKE? Are there any foods to which you are sensitive or allergic? If so, please describe reaction? What is your natural body temperature i.e., are you hot-natured, coldnatured, or in-between? What are your favorite drinks and at what temperature do you enjoy them (hot, warm, icy, etc)? Type of weather, temperature, and environment you most dislike? Please describe what you were like as a child? 5

If you have been bothered by any of these problems, please mark (X) for yes: Headaches Indigestion MEN ONLY Dizzy spells Frequent belching Loss of balance Nausea Burning Blackouts/fainting Vomiting Discharge Back pains Abdominal pain Painful testicles Neck lumps/swelling Constipation Swelling testicles Wear glasses Loose stools WOMEN ONLY Blurry vision Black stools Eyesight worsening Grey or whitish stools Missed period See double Pain in rectum Menstrual issues Eye pains/itching Itching rectum Bleeding between Bloody stools periods Head colds Nose bleeds Frequent urination Bearing down Sore throats Urinary burning feeling Difficulty swallowing Discharge from Hoarse voice Aching muscles vagina Wheezing/gasping or joints Genital irritation Frequent coughing Swollen joints Painful intercourse Cough up phlegm Back or shoulder Breast swelling Chest colds pains Weakness in arms # of pregnancies Runny nose or legs # of births Sneezing spells Painful feet # of miscarriages Sinus problems Trembling # of premature Recurrent colds/flu Numbness births Leg cramps # of caesarians Nervousness/anxiety # of abortions Nail biting Skin rash Difficulty making decisions Scalp problems Lack of concentration Itching/burning Loss of memory skin Lonely or depressed Frequent crying Bruise easily Difficulty relaxing Angered easily Shy or sensitive Annoyed by little things Comments or special problems: 6

Place an X in the appropriate column for any illness that you or your relatives have had. Illness Self Father Mother Brothers Sisters Child #1 Child #2 Child #3 Grandparents Abnormal Periods Alcohol/Drugs Allergies Anemia Arthritis/Gout Asthma Bleeding problems Cancer Diabetes Eczema Emphysema Epilepsy Frequent Infections Heart Trouble Hepatitis High Blood pressure Kidney problems Mental Illness Migraines Polio Pneumonia Prostate problems Psoriasis Rheumatic Fever Stomach problems Stroke Thyroid problems Tuberculosis Ulcers Venereal Disease Weight problems 7

Please mark in the figure below, the locations of physical symptoms; please also write the exact sensation or type of pain you experience at those spots. For example, if you experience throbbing pain on the right side of your head, please mark as shown. THANK YOU!!! 8

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