The Naturopathic Centre

NATURAL DISPENSARY QUESTIONNAIRE

If you are a client of The Naturopathic Centre and wish to access this 24 hour service, please complete the attached form and email it back to the Centre at your earliest convenience. You may prefer to telephone us on 01962 775111, to get some help completing it.

PLEASE COMPLETE AS FULLY AS POSSIBLE
Name
Address
Tel :
What is your main complaint? Please give as much detail as you can
When did this start?
Is there any reason you can think may have that started it?
When do you problems occur mostly?
What time of day or night is worse for you?
What do your symptoms feel like?
Please describe any physically visible symptoms (ie. Is there any swelling, discolouration, skin eruption or change in colour or any discharge,(mucus/stool/urine).

Has there been any general changes to how you usually feel? E.g.:

Are you hotter or cooler than usual?

Are you more or less thirsty than usual?

Have your bowel or urination habits changed?

Has your appetite changed?

Are you perspiring more than usual?

Is there a particular food you are craving?

Are any foods making you feel better or worse?

Is your normal sleep pattern being affected?

Is there any change in your complexion?

Do you like being comforted or rather be left alone?

Are there any changes to how you are normally affected

by noises, light or temperature?

Do you have any aches or pains? If so where are they? when do you get them? And What do they feel like?
Dose movement or posture affect your symptoms?
How do you feel in yourself? E.g. :(happy, sad, restless, irritable, anxious etc…)
Please list any illness’ you have currently with details of any treatments or medications you are having:
Is there are other information you would like to add?
Please return forms by 12 0’clock midday to ensure next day delivery