Dear Patient,
Thank you for choosing homeopathy. To help us understand your health condition better, please fill out this form carefully. We take a full view of your health; body, mind, emotions, and lifestyle; to find the most suitable remedy for you.
Once you complete the form, kindly email it to [email protected]. Please allow up to 2 working days for a reply. If your case is suitable for online consultation, we will send you payment instructions. After payment, you’ll receive a full treatment plan with guidance.
1. About You
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Full Name
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Email Address
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Phone (with country code)
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Address (including country)
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Date of Birth
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Gender: Male / Female / Transgender
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Marital Status: Single / Married / Divorced / Widowed
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Children (number)
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Height and Weight
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Physical description (e.g. skin tone, body type)
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Work status: Full-time / Part-time / Retired / Student / Other
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Occupation
2. Why You’re Contacting Us
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What is your main health concern?
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When did it start?
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What do you think caused it?
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Have you had this problem before?
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What makes it better or worse?
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How does it affect your daily life?
3. Your General Health
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What type of weather affects you badly?
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At what time of day do you feel worse?
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How do you feel in sun, wind, or cold?
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Do you like warmth or cold more?
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Which position feels best: Sitting / Standing / Lying?
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Do you catch colds often? When?
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Do you exercise? What kind?
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Do you get motion sickness (car, plane, boat)?
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How do you feel before, during, and after meals?
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What happens if you miss a meal?
4. Food & Drink
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What do you eat in a typical day?
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Any food dislikes, cravings, or allergies?
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What about sweets, sour, spicy, or greasy food?
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Do you drink: Water / Tea / Coffee / Milk / Wine / Beer / Other?
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Do you prefer hot or cold drinks?
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How thirsty are you?
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Do you like salty foods? Do you add salt?
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Do you smoke? How much?
5. Mental & Emotional Health
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When do you feel like crying?
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What makes you anxious, fearful, or worried?
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Do you feel nervous in crowds?
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How do you react when angry?
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Do you feel better when comforted?
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How do you handle stress or waiting?
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Are you fast or slow in talking, walking, eating, or writing?
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How is your:
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Memory
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Focus and concentration
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Willpower
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Mood through the day
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When do you feel low, sad, or hopeless?
6. Sleep
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When do you feel sleepy?
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What makes you restless or drowsy?
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In what position do you sleep?
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Do you sleep well?
7. For Women Only
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At what age did your periods start?
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How regular are they?
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What is the flow like (amount, colour, odour)?
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Any pain or mood changes before, during, or after periods?
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Have you had pregnancies or miscarriages?
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Any other relevant details?
8. Physical Problems
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Any problems with: Vision / Smell / Taste / Hearing?
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Any dental or mouth issues?
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Any skin issues (eczema, acne, warts, rashes)?
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Any diagnosed health condition? Who diagnosed it and what advice was given?
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Are you taking: Homeopathic medicine / Prescription drugs / Herbal products / Supplements?
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Are you in pain? What kind (burning, dull, throbbing, etc.)?
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Complete the sentence: “It feels as if…” when in pain.
9. Your Health History
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List any major illnesses, accidents, surgeries, or hospital stays (from childhood onwards).
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Any family history of health problems (parents, siblings, grandparents)?
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What are your home and family circumstances like?
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What do you enjoy in your free time?
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Is there anything else you want to share?
Final Step
Once complete, please email this form to [email protected]. You’ll receive a reply within 2 working days. If your case is suitable, we will send payment instructions. After payment, you’ll receive your customised treatment plan.
We look forward to helping you on your journey toward better health.
Hussain Kaisrani
Psychotherapist & Homeopathic Consultant
DHMS, BHMS, BSc, MS ST (University of Wales, UK).
www.kaisrani.com
www.facebook.com/hussain.kaisrani
www.youtube.com/kaisrani
