Questionnaire

Consultation Questionnaire

Step 1 of 3

33%
  • Enter the address to which your remedy should be sent. Please give the full address including postcode.
  • Please enter phone number without spaces
  • Please describe the main medical problem with which you want help.
  • Tell me if anything eases or aggravates your condition. (For example "worse when I'm hot", "better in fresh air", "worse from scratching", "better when I move around", etc.) If nothing seems to make any difference, please enter the word NONE.
  • Tell me if the condition changes at any time during the day or night. (For example "worse around 5:00 a.m" or "better in the evening".)
  • If you are currently taking any medication or are receiving any form of treatment (holistic or conventional) for anything please give details. If you are not, please enter the word NONE.