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homeopathic intake questionnaire

Please answer as thoroughly as you can — this helps Terri understand you as a whole person. Everything is private.

1 · Personal information

Full name

Date of birth

Phone number

What brings you to seek homeopathic care?

Your main health concerns or goals

2 · Current health concerns

Describe your main symptoms or concerns in your own words.

When did these symptoms begin?

What was happening in your life when they first appeared?

What makes your symptoms better?

What makes your symptoms worse?

Do your symptoms follow any patterns? (time of day, seasons, weather, activities, stress)

How do these symptoms affect your daily life?

3 · Physical health patterns

Describe your symptoms in detail. (location, sensation, intensity, frequency)

Are your symptoms constant or do they come and go?

How does your body typically respond when you become sick?

Any unusual, recurring, or specific symptoms that may seem unrelated?

4 · Sleep & energy

How would you describe your sleep quality?

Difficulty falling asleep or staying asleep?

Describe your daily energy patterns — when do you feel best and most tired?

5 · Emotional & mental well-being

How would you describe your overall emotional state?

How do you typically respond to stress?

Emotional patterns that seem to repeat throughout your life?

What helps you feel calm, supported, or restored?

6 · Lifestyle & environment

Describe your typical daily routine.

What does your work, school, or home life look like?

How would you describe your relationships and social connections?

Environments or situations where you feel better or worse?

How do you respond to changes, pressure, or new situations?

7 · Food & nutrition

What foods do you enjoy most?

Foods you strongly dislike, avoid, or cannot tolerate?

Do you have specific food cravings?

Do certain foods make your symptoms better or worse?

Describe your typical eating habits.

8 · Personal & health history

Childhood health and significant childhood experiences.

Major illnesses, injuries, surgeries, or stressful events that impacted your health?

Health patterns or conditions that run in your family?

Previous treatments that have helped or not helped?

Have you tried homeopathy or other natural approaches before?

9 · Unique health patterns

Symptoms or experiences that feel unique or unusual to you?

Anything about your health that's been overlooked or misunderstood?

Details about your health journey most important for Terri to know?

10 · Goals

What changes are you hoping to experience through homeopathic care?

What does improved health look like for you?

What areas of your life would you most like to support?

Physical health Energy Sleep Stress management Emotional balance Digestion Immune support Other

Anything else you'd like Terri to know?

Your answers are sent privately to Terri.

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