Deborah Olenev, C.C.H.
59 Paul Avenue
Mountain View CA 94041
(650) 569-6219 voice mail
Olenev@att.net
www.homeopathyforhealth.net
Teen Questionnaire for Homeopathy
What is your name?
What is your date of birth?
What is your address?
What are your phone numbers?
What is your e-mail address?
Please answer as many of the following questions as you can in preparation for your initial consultation. If you find this difficult to do, don’t worry about it, we will explore further during your session, and I will help you tell me the story of your illness.
Please tell me about the genetic background of the family: diseases of parents, grandparents and siblings.
Physical Sphere
1) What are your physical complaints? When did each of them begin, and what makes them feel better or worse?
2) What foods do you have a craving for? Are there any foods that you have an aversion to? Are there any foods that aggravate you in any way?
3) Please tell me what you eat on an average day for breakfast, lunch, dinner and snacks?
4) How thirsty are you? What do you like to drink? Do you use ice in your drinks?
5) Please tell me what your physical and emotional responses are to the following weather conditions: sunny weather, rainy weather, thunder and lighting storms?
6) Would you say that you are more sensitive to the heat or cold? Are any parts of your body colder or hotter than other parts?
7) Is there a natural environment that you prefer or feel better at? For example, ocean, mountains, desert.
8 ) Do you have any problems with sleep, such as frequent waking, or difficulty falling asleep? Do you like to sleep well covered, or do you uncover your arms or feet? What is your favorite sleep position?
9) What is the time of the day when you feel most energetic? What time of the day do you feel most tired? Please be specific as to times, and let me know from when to when? What time are your symptoms most troublesome?
10) How often do you catch colds? What symptoms do you typically have during a cold?
11) For women: How are your periods? Are you experiencing any PMS symptoms? If you are in menopause or perimenopause, are you experiencing any problems?
For men: Do you have any sexual problems, please explain.
12) What kind of exercise do you do? Do you feel better or worse from exercising?
13) Do you have any problems with your skin? Please describe.
14) Do you have a tendency to perspire, day or night, and on which part of your body?
15) Have you experienced any accidents, which have caused health problems?
16) Are your fingernails and toenails healthy? Please indicate if there is any thickening, ridging or discoloration of the nails.
17) What medications are you taking, and what are they for?
18) Have you had homeopathic treatment in the past? Please let me know the remedies you have taken, the potencies, the dates you took them and about your response to the different remedies. Also, please me know about other treatments you have had for your health conditions.
Personal History
This section is very important to my understanding of your case, so please do not forget to complete it.
1) Please tell me about your personal history, starting with any information you have about your mother’s pregnancy and delivery.
2) Please tell me about the childhood illnesses you have had.
3) Please tell me about your family situation, and your relationship to your parents and siblings.
4) Please tell me about how you are doing in school, and if you have had any learning challenges.
5) Please tell me about your social life and your interaction with your friends.
Emotional Sphere
1) What are the activities you enjoy doing?
2) Are you a moody person? What are the moods you tend to go into? Do you get depressed or cry easily?
3) Do you tend to get angry or impatient? Do you show your anger openly or try to hide it? How do you express your anger?
4) What are your fears? Are there any situations where you feel anxious? Do you fear any animals?
5) Are you a worrier? What do you worry about?
6) Do you have a tendency to dwell on the past?
7) When you are feeling upset do you want consolation, or to be left alone?
8 ) Are you a sympathetic person?
9) Are you perfectionistic in any area of your life? Which areas?
10) Do you tend to be neat or messy at home and at work?
11) Are there any types of people that you do not get along with?
12) Do you like to read, and if so, which types of reading matter?
13) Do you experience nightmares, or recurring dream themes? If you would like to, you can tell me a dream that you feel is significant.
14) When you have an appointment, do you tend to arrive on time, or do you come late? How late do you run?
15) Would you say you are a hurried person, or slow?
16) Have you had any addictions in your life? Do you have any bad habits, such as nail biting?
17) How do you feel about animals? Are you a big animal lover, or are you neutral or indifferent to them?
18) Do you have a jealous streak?
Mental Sphere
1) Do you have any problems with your memory? What kinds of things do you have a problem remembering?
2) How is your concentration? Do you get distracted easily, or have difficulty focusing your attention on tasks?
3) Are you religious? Do you have a prayer or meditation practice?
4) I mentor homeopathic students and visiting homeopaths from time to time. Would you be willing to allow another homeopath to sit in on the case taking process?
Thank you for completing this questionnaire.
