Questionnaire Consultation Questionnaire Step 1 of 3 33% Name* First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Enter the address to which your remedy should be sent. Please give the full address including postcode. Email* Phone*Please enter phone number without spacesAge (years)*Gender*MaleFemaleMain Reason for Consultation*Please describe the main medical problem with which you want help.What makes the problem worse or better?*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.Is the medical problem worse or better at any specific time?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".)Are you taking medicines or receiving any other treatment?*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. Allergies*If you have allergies, tell me what you are allergic to and how the substance affects you. If you don't have any allergies, please enter the word NONE.Natural hair colour*What is the natural colour of your hair (without hair dye)? If your hair is now grey/white, what was the original colour?Eye colour*What colour are your eyes?Food cravings* Sweets, cakes or biscuits Chocolate Butter Bread Coffee Wine Beer Other alcoholic drinks Milk Fruit Salty food Spicy food Fried food Eggs Other food or drink (not listed) I don't crave any food or drink Are there are any foods or drinks that you crave or would find it difficult to give up? Select as many as appropriate.Anxieties or Fears* I worry a lot about the future I worry a lot about my health or about dying I have to check everything several times over I worry a lot about other people's health I feel anxious during thunderstorms I feel anxious in narrow spaces I feel anxious when I go outside I am afraid of heights I am afraid of the dark I am afraid of birds I am afraid of some other animals I worry about robbers or intruders in my house I worry that somebody is following me I worry that I will go insane My anxieties or fears are not on this list I have no significant anxieties or fears What do you worry about? What makes you feel anxious? Select as many as appropriate.Personality Traits - part 1* I am very affectionate I have to keep busy all the time I find it easy to sit and relax (when I have time) I am friendly and open I am rather reserved and private My home and/or office are always tidy My home and/or office are usually untidy I am intellectual I never seem to have any energy I feel better after exercise I feel worse after exercise I weep easily and I need consolation When upset I go somewhere to weep by myself I don't cry even when I am really upset I can't cope with sympathy. It makes me feel worse I often feel jealous I often feel full of despair I get angry easily I am usually calm My moods change frequently I love to spend money I try not to spend more money than I really need to Which of these descriptions apply to you? Tick as many as appropriate.Personality Traits - part 2* I find it hard to forgive past grievances I often feel irritable I have to be the one who makes decisions I tend to go along with other people's choices I am very stubborn I am self confident I have low self confidence or self esteem I am rather lazy I find it hard to make decisions I am too generous I am still grieving the loss of a loved person or pet I find it hard to remember things I have a good memory I am very sensitive to criticism I am critical of other people I don't like being by myself I enjoy spending time by myself I am very particular about my clothes and appearance I don't worry about my clothes or appearance I am a perfectionist I have many ideas but seldom put them into action Religion is a major part of my life Which of these descriptions apply to you? Tick as many as appropriate.What type of work do you do?This helps to identify environmental and/or stress factors in your life. If you are retired or temporarily unemployed, what type of work did you do? Which weather conditions make you feel good? Hot, dry weather Hot, wet weather Cold, dry weather Cold, wet weather Windy weather Sunshine Fog Thunderstorms Other weather conditions (not in this list) In which type of weather do you feel generally better or happier? Tick as many as appropriate.Which weather conditions make you feel bad? Hot, dry weather Hot, wet weather Cold, dry weather Cold, wet weather Windy weather Sunshine Fog Thunderstorms Other weather conditions (not in this list) In which type of weather do you feel generally low or unhappy? Tick as many as appropriate.What is your body shape?*Short and overweightTall and overweightAverage height and overweightShort and thinTall and thinAverage height and thinShort with muscular/athletic buildTall with muscular/athletic buildAverage height with muscular/athletic buildShort with average buildTall with average buildAverage height and average buildWhich of these descriptions fits you best? Tick one.Do you have skin problems?*If you have problems with your skin please tell me about them. If you don't have any skin problems please enter the word NONE.Do you have any problems with your teeth or nails?*If you have any problems with your teeth or nails please tell me about them. If don't have any problems with them please enter the word NONE.Females only - What are your periods like?Please describe your menstrual cycle. Are your periods regular? Are they heavy or light? What colour is the flow? Are there clots? Do you suffer from PMT and if so, at what point in the menstrual cycle are your moods most affected? If you are menopausal or post-menopausal, please tell me what your periods used to be like.All clients - Other medical problems or additional informationUse this space to tell me about any other medical problems that you have, or any other information that you think will be useful.Type of consultation required*Email consultationPhone consultationConsultation in personConsultations in person are available within 40 minutes' drive from Mablethorpe, Lincolnshire.Do you want a copy of your answers?*YesNoIf you would to receive a copy of your answers please select "Yes". It will be sent to the email address specified in this form.