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  • Questionnaire

    First Name:


    1. What is your chief complaint (CC)? Tell as much about it as you can, including what is the worst part of it and why it's the worst: the sensations, the kind of pain, the location, how your energy has been affected (for example, has the complaint made you restless, weak, nervous, anxious, irritable, hypersensitive, effected your thirst and appetite, your body temperature, and so on).

    2. When did this problem begin? What happened in
    your life around that time? What do you think
    caused it?
    3. What aggravates the CC and what brings it on?(for example, certain types of food or weather, movement, light, noise, company, talking,
    heat/cold, or anything else that you can think
    of; please be specific) and what makes the CC better (for example hot or cold, massage, eating, lying still, music, company...)? What does it make you do to try to feel better?
    4. At what time of the day or night is the CC the
    worst? Specify an hour if you can.
    5. What symptoms can you identify that accompany
    the CC (whether directly related or not; for example, headache with nausea; or menstrual cramps with diarrhea; a cold with irritability and anger)?

    6. Environment: With regard to the seasons, weather, outdoor temperature, indoor temperature, drafts, air quality, airconditioning, ocean air, mountain air, humidity, the sun/rain/thunderstorms/clouds/fog, etc.: what environmental factors give you comfort and relief, and which ones cause discomfort and distress? Try to give examples.

    7. What position is most uncomfortable for you?

    8. a)Do you tend to be chilly or warm? Are there parts of your body that are colder or warmer than the rest of you? Is there a special time of day or night when they are colder or warmer? b) Do you perspire a great deal? If so, when? And where on the body? (feet, head, hair, chest, armpits, etc) Does it leave a stain of a particular color? Is there a particular odor?
    9. Describe what your tongue looks like.

    10. What do you worry about? How do you deal with
    11. How do you keep your house/your desk/your room/your study/your bathroom?
    12. How easily do you cry? In what situations?
    13. When you are upset, what do you do to help yourself feel better?
    14. What makes you angry? What do you do when you're angry?
    15. Do you have an emotion that predominates; such as anger, depression, irritability, anxiety, jealousy, joy...or possibly two emotions that tend to alternate predictably?
    16. What fears do you have?
    17. What have been the most difficult circumstances in your life? How did you cope?
    18. What are the greatest joys you have had in
    your life?
    19. What was your childhood like?
    20. What bothers you most in other people? How,
    if at all, do you express it?
    21. What causes the most problems in your relationships?
    22. Do you have any recurring dreams? What are they about?
    23. What would you need to feel happy?
    24. What do you do for work? Ideally, what would
    you like to do?
    25. If you were made President for a day, what would you change?
    26. When people have criticized you, what were they complaining about? Similarly, when people have praised you, what did you receive praise for?
    27. What would you like to change most about

    28. How do you feel before, during and after
    meals? How do you feel if you go without a
    29. What would you most like to eat (if you did
    not have to consider calories, fat, anything
    you've read about the right way to eat)?
    30. What foods do you dislike and refuse to eat?
    What foods do you react badly to, and in what
    31. How much do you drink in a day? Include
    sodas, juice, coffee, tea, milk, and
    alcoholic beverages as well as water. How
    thirsty do you tend to get? What temperature would you like your drinks to be?

    32. How is your sleep?
    33. Do you do anything during sleep? (speak,
    laugh, shriek, toss about, grind your teeth, drool, snore, walk, talk, etc.)
    34. Do you have trouble falling asleep? What keeps you awake? Do you wake always at a certain time? What causes you to wake up? What position do you sleep in?

    35. Number of pregnancies, number of children,
    number of miscarriages, number of abortions
    36. At what age did your menses begin? If you
    have gone through menopause, at what age?
    37. How frequently do they (or did they) come?
    38. What about their duration, abundance, colour,
    time of day when flow is greatest; any odour
    or clots?
    39. How do you (did you) feel before, during and
    after menses?

    40. What medications are you taking at present?
    41. How frequently do you get colds and flus?
    42. Have you had any childhood illnesses twice,
    or in a very severe form, or after puberty?
    43. Have you had any vaccinations since the
    standard childhood ones? Have you ever had an
    adverse or unusual reaction to a vaccination?
    44. Have you had any surgery? What and when?
    45. Have you had at any time (mention year):
    warts, cysts, Polyps, or tumors? Where were they located? How were they treated?

    46. Do you tend to have any discharges (nasal,
    vaginal, etc.)? What is the color, consistency?

    47. a) Do you tend to need a smaller dose of
    medications than most other people?
    b) Do you need less anaesthesia than others,
    or have a hard time coming out of it?
    c) Do you tend to react to vitamins and herbs
    and/or need hypoallergenic vitamins?
    d) Are you sensitive to paint fumes, exhuast,
    dry cleaning fluid, fragrances etc.?

    48. Family history: Mention diseases, causes
    and ages of deaths of father, mother,
    sisters, brothers and grandparents on both

    49. Construct a time line: Mention from birth
    on to the present day, all IMPORTANT events
    (emotional and physical traumas,
    heartbreaks, divorces, work-related events,
    diseases or traumas your mother had while
    being pregnant with you, family stress,
    death in the family or of friends,
    disappointment, etc.) Mention the symptoms
    experienced at those moments or which you
    can date to those traumas.
    50. When you stand in line at the bank or supermarket, how do you feel?
    51. When your family member was last sick, what did you do?
    52. How is your sexual energy?
    53. How do you react to consolation
    54. What part of your life do you have the most difficulty coping with.
    55. What are your hobbies?

    [ 30. March 2003, 18:39: Message edited by: Snoopy ]

  • #2
    People should feel free to suggest amendments, additions, corrections, etc. to this questionnaire.



    • #3
      I would just get people to answer the same standard questions I ask in clinic.

      1.What is the main reason you need treatment?

      2.Describe your complaints giving the following details:

      a. What does it feel like?
      b. When does it happen?
      c. What sort of things make it worse?
      d. What sort of things make it better?
      e. What else was happening when it first appeared?
      f. Describe the quality of the pain, being as creative as you can. How would someone else imagine the pain happening to them?
      g. What does it look like?
      h. Do any other symptoms occur immediately before, during or after?

      3. What illnesses have you had in the past?

      4. What illnessess run in the family?

      5. What do people die from in the family?

      6. What medication are you on?

      7. What foods do you crave, whether you allow yourself to eat them or not? List from the strongest craving to the weakest.

      8. What foods do you have an aversion to? (hatred or repulsion for)

      9. What is your level of thirst, and what do you prefer to drink?

      10. What foods aggravate you? (including allergies)

      11. Do you suffer from any digestive complaints? What is your bowel habit like?

      12. What is your level of energy like? Rate it from 1-10 (10 being excellent). How does your energy fluctuate throughout the day (and night)?

      13. What is your level of sexual energy like?

      14. How is your sleep? What position do you prefer to sleep in? Is there any position you cannot sleep in? Any unusual behaviour during sleep?

      15. Have you had any reoccurring dreams or images/ pictures/ themes that repeat themselves in your dreams? Please describe.

      16. Describe your menses (periods). Describe any PMS. Have you been through menopause? Any gynecological problems?

      17. How does the weather affect you? Are you sensitive to the temperature in any way?

      18. Is there anything else in the environment you are sensitive to, perhaps more so than the people around you?

      19. What is the worst thing that has ever happened to you? Describe in detail.

      20. What part of your life do you have the most difficulty coping with? Why is that?

      21. What was your childhood like? Describe your parents and your relationship with them. Describe your relationship with your siblings and other extended family members. Did anything in your childhood have a profound effect on you?

      22. Describe the romantic relationship you are currently in. What causes the most problems between you?

      23. What is your occupation? What differentiates you from the other people in your place of employment? What difficulties do you have at work?

      24. What is your self-confidence like? When is your confidence at its worst?

      25. What fears do you have? Do you have any phobias? What things in life do you have trouble facing?

      26. What parts of yourself or your life would you change if it were at all possible?

      27. What do you do to relax?

      28. What is something that you have told nobody else, or at least very few people? Why is that?

      These are the basic questions, none of which will elicit a specific answer, and allow the patient complete freedom to go wherever he or she wants with the consultation.
      David Kempson.<br />Dip.Homoeopathic Medicine.<br />Lecturer Australian College of Natural Therapies (Brisbane Campus)<br />Member AHA, AROH, HMA<br />Member Australian Homoeopathic Association. Member#0442.


      • #4
        I have a definite prejudice against questionaires. I think it's better to ask the person to tell me anything they want me to know about themselves and what they came to see me about.

        When they run down, I stay quiet for a few minutes and they usually start up again. If not, I ask 'What else?' As they are speaking, I try to write down everything they say in their own words. In the margins of the case study, I make notes of remedies that come to mind and star the items that I want more information on.

        Eventually, they are completely run down. I then go back over the case and ask questions about the items I have starred. Once that's done, I ask questions that would give me more information as to the suitability of the remedies I noted in the margins.

        It's only after that process is completed, if no remedy is obvious from the case so far, that I then ask what I hope are open ended questions based on the types of items in your questionaire.

        However, when I analyse and repertorize the case, I try not to use anything that was not freely offered by the client. I only use the answers to my questions if more than one remedy is strongly indicated based on the client's own offerings.

        It's a little harder when someone is new to homeopathy, but with some coaxing, they usually begin telling me what I need to know. If someone is naturally taciturn, then that becomes part of the case. I know that on the internet, it's a lot easier to use a questionaire, but I find it hard to determine what's most important to the person who answered the questions.
        Shirley Reischman


        • #5
          Shirly, I agree completely. I only ask any of these questions when the patient is silent and does not know what to say to "Anything else?".

          In preference, I just let them ramble on. I think it is quite different when people are writing (typing) instead. People are less inclined to ramble.

          Questionares by their nature are leading. Still, they offer some structure to those who have no idea where to begin.
          David Kempson.<br />Dip.Homoeopathic Medicine.<br />Lecturer Australian College of Natural Therapies (Brisbane Campus)<br />Member AHA, AROH, HMA<br />Member Australian Homoeopathic Association. Member#0442.


          • #6
            I would like to add to David's list:-

            Tell me about anger. What makes you angry and how do you react?

            As above, to unhappy, happy, amd jealousy.

            I always ask the reaction to consolation,and their earliest memory.

            If I have children in I ask for 3 wishes and for adults , what they would change if they could be prime minister for a day.

            If they work in a managerial position I ask then to describe their leadership stategy and how they manage their staff.

            Naturally I hope not to have to ask any questions but that the patient will just talk and often they do without any interference.
            RSHom - Registered Homeopath


            • #7
              Any questionanaire the patient picks is going to assist the practitioner. It saves us from having to rewrite the questions every time; because inevitably, someone writes in with a problem, and they say, "I have ______ disease" and they give no information that a homeopath needs to know, especially the modalities. They don't give the onset, the etiology, the concomitants, the food desires, the sensations, the color of the discharges, and so on. In this context, any questionnaire they pick is going to be a bonus for us.

              I agree that someone who writes in with an acute problem shouldn't be faced with 55 questions, because what we really want to know is, what is different about you since you became sick.
              So, we really want to make sure that we either have an acute questionnaire, or we say, On the "Questionnaire", just answer the part dealing with the chief complaint.



              • #8
                Case Taking Guidelines - The Herscu Method

                Questionnaires can be dangerous but may also be very helpful after you have taken the main case to look for confirming symptoms. However, it is more important to find the true chief complaint and to ask questions of how they deal with it and what it leads them to do. It is the excessive use of energy in response to stress that prevents the body from healing itself. Reduce the responses to stress and the body will heal. The simillimum will restore the imbalance in the vital force by reducing the excessive use of energy as a response to the stress that caused the illness.

                Observation: Often times the true chief complaint, what really needs fixed can be observed. Finding the true chief complaint is critical. A patient may come in and shake your hand in a weak way, may not make direct eye contact and when you ask them why are you here they say "I get these terrible headaches and as they say it they laugh and act awkward. It should become obvious while the headache should be analyzed in terms of modalities, etc, the fact the patient acts this way is peculiar and in the end may prove to be a main segment of the case. If this is not an obvious issue upon observation it will come out in questioning as noted below, so you do not have to find key symptoms by observation but I state this to show how important it can be.

                Follow the energy and what the worse thing is about the chief complaint. Ask what is the worse thing about the headaches? Then ask why that is so bad for you? Then ask more questions until you have exhausted all possible responses or find similar ones to confirm it is a major issue for the patient.

                Then ask what they do when they have a headache, as this will give you their response to the stress of the headache, which the response is one thing that will need fixed. They may say they want to be alone. Ask why and you will find a logical reason to continue to build the case upon.


                What is the worse thing about this for you? And why is this so bad for you?

                How symptoms make them feel (quality of symptom) and ...

                What symptoms make them do in their attempt to respond to the stress – the way they use energy to strain is what needs fixed.

                And how they get symptoms…

                By asking these questions over and over you not only get more symptoms but how the symptoms impact the patient and how one symptom leads to another. This is how you find the deeper state and what needs fixed, and it will form a logical cycle showing the patients response to stress.

                SAMPLE CASE TAKING:

                40 year old women Chief complaint: Migraines

                Lets say a patient comes into your office and says, " I get these terrible headaches and while telling you this she is almost laughing. You realize this person is acting awkward and it is peculiar for a person to think or act like there is something funny about having migraines. Make note of this laughing immoderate and acting awkward or childish, as it is peculiar and very well may be part of the case. But as noted above it is not mandatory that you pick up on this as the case will unfold with proper questioning and this will come out as noted below.

                What’s the worse thing about having a headache?

                I have to be alone and cannot accomplish things. Why do you have to be alone? Because being around others makes it worse. What’s the worse thing about being around people. I worry how people view me, what they think of me and I get anxious just talking to them. (You can see they are nervous talking to you as well)

                They worry how people perceive them and upon asking more questions it is obvious they are (full of cares and worries about many things that build up and eventually (develop migraines, swelling,etc) this leads them to …..

                be timid and embarrassed easily around others as it hurts them in some way and you ask questions about in what situations and find out strangers, group meetings, in public, etc, etc so it is a major issue for the patient that leads to make them……

                withdraw and constrict or close off (company aggravates, desire to be alone)

                So when you are alone how do you feel? They say I feel confused? What’s the worse thing about feeling confused? I don’t feel I know who I am? Why is that so bad? I guess because I start 2nd guessing myself and I do not know how to act. (lack confidence and have confusion of identity) and this leads them to…..ask the question…

                What do you do when you feel this way?

                I do not like to be alone when I feel this way and need to be in company. Why does that help you? Because talking to others makes me feel I am ok. (They try and do something different to escape this feeling (need to communicate or change- loquacity)

                So talking to others helps you but how do you feel talking to others. It helps at first but I feel I can not control myself (loss of inhibition) and it seems I end up feeling awkward and end up saying something wrong/inappropriate and feel stupid (awkward in a forced out shy type way (anxiety talking) )

                Question: Well everyone says things they regret, why is this so bad for you?

                Answer: it makes me feel like a failure and they become embarrassed again and the worse thing for them as noted above is they have to be alone again and cannot accomplish things and the cycle continues.

                At this point you pretty much have the whole case but can now ask questions to find confirmations or supporting symptoms of the grand characteristics or segments above of the main ideas of the patient in terms of their response to stress, how they feel and what it makes them do. Now you ask the questions about how they were raised/family to try and find out why they are timid and act awkward and you will usually find out a logical reason why such as mortification, controlling parent, etc. You can then ask about food cravings, temperatures, family history, sleep and for example stools and sure enough you find yet another key note symptom of the patient and the remedy. When you found out about they are anxious in company and talking to people ask for other times they are anxious. Ask about sex life, stools, etc and in this case you will often find out they have a great deal of anxiety if they have to pass a stool in the presence of others. All of these are keynotes of the patient and the remedy.

                This is the summary of the cycle for Ambra Grisea

                Awkward or slightly inappropriate behavior &gt; becomes timid and embarrassed &gt;withdraws from state and becomes closed and constricted & (aversion company, anxiety talking) and &gt; becomes confused as to who or what she is and what she wants (lack confidence and confusion of identity) &gt; worries of how people perceive her (full of cares) and worries and things build up inside them (migraines, constipation etc) &gt; tries to do something different to break out of feeling .(desire company and need to communicate but become to loquacious or outgoing ) and eventually says something or does something awkward again and fails in some way.

                Once you know the true chief complaint of what really needs fixed, Herscu gives you a method of logical questioning that covers all the standard case taking questions you need to discover such as the etiology, modaliteis, family history, etc and includes new concepts such as the opposite of the chief complaint, the nightmare of the opposite of the chief complaint which are the main reasons or symptoms as to why the patient can not break the cycle and keep doing thinks in response to stress that keep them sick and these are the symptoms that make the case.

                I have read in Herscu’s 2 year class and in the “Herscu Letter” 100's of these cycles of remedies and compared to any other materia medica the picture of the remedy becomes crystal clear, includes most of the main symptoms you want to find in order to prescribe with confidence and it is written in modern day terms and symptoms. This gives you an incredible understanding of remedies like nothing else I have read. The logical connection of how one symptom or set of symptoms leads to another in forming a cycle is invaluable and in fact is necessary to find the pattern of the persons response to stress that the patient is stuck in causing chronic illness. The main 4 types of questions to continuously ask as noted above will help find the main symptoms of how the patient uses to much energy in their individual response to stress.

                If anyone who knows homeopathy fairly well was to read about 100 remedies and their cycles in terms of what are their true grand characteristics and if a person learns Herscu's method of case taking, not only does there success rate go up, they save a great deal of time in case taking. I cut my time in half as once you find the true chief complaint - what really needs fixed and then build the case around it looking for logical connections of symptoms/main ideas of how the patient is responding to stress on a physical, mental and emotional level. Then, homeopathy becomes almost scientific in case taking and in results! Also his method of compiling symptoms from provings uses this format and again you have a very clear picture of what the newly proved remedy is really about.

                Again, I am not an expert at this but have had great success with it and I am only ½ way through Herscu’s, 2 year course. The “Herscu Letter” is invaluable but you have to get through 12-13 letters to really understand what he is doing and all of a sudden it hits you what you are trying to do as a homeopath and it is truly enlightening. The Herscu letter is only $19 per month. The 2 year course is outstndaing as that is when you get all the cycles for over 100+ remedies. It is expensive but will cut your case taking time and analysis time in half!
                Most importantly you will cure many more people quicker and more efficiently.


                John Oljace
                Perennial Medicines


                • #9
                  Dear John,

                  Thank goodness a Herscu student finally showed up here! I hope you'll stick around to teach us this method.



                  • #10

                    Thank you for the kind words. I really like the responses and attitude and dedication of people at this site. I am slowly developing 2 websites of my own with a little bit different purpose but have forum and many other things to offer but no time to really manage them much for now.

                    You may want to see Herscu discussion as I go into some of what he does and it is different but the line of questioning noted is very helpful but need ot learn whole method to really uinderstand it. The Herscu letter is a great place ot start but need to get through 13 letters to understand what his method relaly does for you and it is amazing.

                    Thanks agian for your kind remarks.

                    John Oljace
                    Perennial medicines


                    • #11
                      Dear members

                      The term homeopathy is formulated and defined by Hahnemann in his Organon and chronic disease.
                      This definition forms the basis of discussion.
                      It is the disease- signs and disease-symptoms, which call forward the curative remedy by similitude in homeopathy.
                      It is the disease which needs treatment and not the person as such.
                      When talking of homeopathy, Hahnemann refers to the disease throughout his works, and not to human existence as such being disease.

                      There are many healers who think they are homeopaths and have not realized what homeopathy is. They then talk of forms of homeopathy without knowledge of the truth.

                      Let us look into this idea, that homeopathy treats the person and not the disease.
                      This would mean, that NOT the disease-symptoms are the indications for the selection of the curative remedy.
                      This means that the remedy should not cure the disease but should cure the person.
                      If it is to cure the person, then it would eliminate the person.
                      This would lead to an ‘’endloes’’ kind of treatment: patient gone—disease gone.
                      Hans Weitbrecht
                      HOMEOPATH / IRELAND


                      • #12
                        I have never seen a disease walk into my office by itself that was not attached to a person or an animal. This is an unnecessary demarcation and really shows the polarity or mind split in those who are content to see all causation only in a literal and linear reality - which completely denies the existence of synchronicity and "analogy in agreement with experience".


                        • #13
                          I agree with ChrisG

                          Another way to look at this is you treat the disease and you treat the persons response to the stress/disease. In fact if you look at rubrics you select for most cases you are treating both the disease and the persons response to disease and in fact that is another part of the idea of treatinbg the totality of the disease.

                          Picking remedies just on specifics about the disease without the rubrics in terms of how the person responds to the disease is happhazard and only part of the time will you find the simillimum. This is one reason why so many cases are not cured.

                          I see many cases at the BB where homepaths pick a remedy on one peculiar symptom and yet I seldom see that case continue to get postings or news the person was cured. This happens all the time at this site and you think these people would get a clue...such is life in homeopathy!

                          While peopel may not agree, while the disease
                          and modlaities and peculiar issues ar ea consideraiton, the persons response to it is more important in remedy selection as it is their response be it physical symptoms, emotional or mental that show they are strianing against the stress that needs to be reduced for the body to heal itslef.


                          [ 10. November 2002, 15:21: Message edited by: john oljace ]


                          • #14
                            A beautifully designed questionnaire is available on the following link

                            <b><a href="">drsalim@inbox.c</a></b>


                            • #15

                              Did you manage to give a final shape to your questionnaire after receiving feedback. If yes, please post it so that we may benefit from it.

                              Don't take life too seriously, it aint permanent.