Homoeopathic Questionnaire

Don't worry if you feel you cannot answer any questions as they can be discussed at the consultation.
Owners name

Prefix First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

postal code Country
Phone Number

Area Code Phone Number
mobile number
E-mail
Pets name
Species
Breed
Sex
Birth Date

Month Day Year
Last Vaccination

Month Day Year
Current Diet
Registered Vet
Insurance Details

What is the presenting problem?, describe as detailed as possible
Does anything seem to worsen the symptom (e.g. weather, temperature, rest, motion?)
Does anything seem to improve the sympton?
When is the symptom worst (e.g. season, time of day?)
Duration of problem (and any regularity in timing of symptoms returning.)
Circumstances at the start of the symptoms (e.g. disease, injury, new family member, death in the family, vaccination.)
Concomitant symptoms (e.g. if sneezing, is there a nasal discharge? if so what sort? if diarrhoea, is there straining?)
Past medical history (previous treatments, vaccinations, other complaints.)
Present treatment/ medication.
Family history of pet (pedigree and relative problems if known.)